“Which is the best epilepsy medication?” is one of the questions I encounter most often in my clinic. However, I must say from the outset that there is no single answer to this question. In epilepsy treatment, the concept of the “best drug” is a fully individualized decision that varies according to the patient’s seizure type, age, sex, comorbidities, and even lifestyle.
According to World Health Organization data, approximately 50 million people worldwide live with epilepsy. While the vast majority of patients can lead seizure-free lives with appropriate drug treatment, about 30 percent may present with a picture of drug-resistant epilepsy. In this article, drawing on my experience in neurology practice, I will discuss current drug options in epilepsy treatment, the drugs preferred according to seizure type, and the mistakes frequently made during treatment.
How Does Epilepsy Medication Work?
Antiepileptic drugs (AEDs) work to regulate the imbalance between the excitatory and inhibitory systems in the brain. These drugs act mainly through two pathways: first, by affecting the ion channels (sodium, calcium, potassium) in nerve cells to regulate electrical activity; and second, by modulating neurotransmitter systems (especially GABA and glutamate) to suppress excessive excitation.
There is a critical point that must be emphasized here: antiepileptic drugs do not “cure” epilepsy — they prevent seizures. In other words, these drugs do not eliminate the underlying epilepsy process; they raise the seizure threshold, making it harder to have a seizure. For this reason, regular use of the medication and not stopping it without a doctor’s approval are of vital importance.
Drug Selection Based on Seizure Type
Drugs Preferred for Focal (Partial) Seizures
Focal seizures are seizures that begin in a specific region of the brain. For this seizure type, according to current guidelines, carbamazepine, levetiracetam, and lamotrigine stand out as first-line treatment options. Among the newer-generation drugs, lacosamide — which acts through a different sodium channel mechanism — has become an increasingly common clinical choice, particularly in recent years.
Cenobamate, meanwhile, is a notable new molecule in focal epilepsy since the 2020s. Studies have reported that it shows high efficacy in focal-onset seizures.
Drugs Preferred for Generalized Seizures
In generalized seizures, which affect the entire brain, valproic acid has long been regarded as the gold standard owing to its broad-spectrum effect. Ethosuximide is prominent for absence seizures, while valproic acid and levetiracetam stand out for myoclonic seizures.
Important warning: some drugs, such as carbamazepine and phenytoin, can worsen seizures in certain subtypes of generalized epilepsy. For this reason, correctly classifying the seizure type is the most critical step in drug selection.
Drug Selection in Women and During Pregnancy
In women of childbearing age, the use of valproic acid is subject to serious restrictions because of its teratogenic (birth defect) risk. In this patient group, lamotrigine and levetiracetam are preferred due to their safer profiles. Every epilepsy patient planning a pregnancy should absolutely review their treatment with a neurologist.
Old Generation or New Generation?
Epilepsy drugs are generally classified as old-generation and new-generation. While older drugs such as phenobarbital (the first anticonvulsant, in use since 1912) and phenytoin still have a place in clinical practice, the new-generation drugs introduced from the 1990s onward (lamotrigine, levetiracetam, lacosamide, brivaracetam, perampanel, etc.) generally offer the advantages of fewer drug interactions and better tolerability.
However, “newer = better” is not always correct. Some older drugs may still be the most effective option in certain epilepsy syndromes. What matters is not the age of the drug, but its suitability for the patient.
5 Common Mistakes in Drug Treatment
Stopping the medication on one’s own: Even if seizure freedom is achieved, abruptly stopping the medication can cause prolonged seizure crises known as status epilepticus, which can be life-threatening.
Skipping doses: Irregular use of medication leads to fluctuations in blood levels and impairs seizure control.
Abandoning medication in favor of alternative medicine: Herbal treatments or alternative methods have no proven efficacy in epilepsy treatment.
Not telling the doctor about side effects: Side effects such as drowsiness, balance problems, and skin rash may require a change in treatment; failing to report them reduces the success of the treatment.
The “what works for everyone will work for me too” mindset: A drug that works in another patient may have the opposite effect in you. Treatment must always be individualized.
What Is Done If Drug Treatment Is Not Enough?
In approximately 70 percent of patients, seizure control can be achieved with a single drug. However, if seizures continue despite trying two or more appropriate drugs, the diagnosis of “drug-resistant epilepsy” comes onto the agenda. In this situation, the options to be evaluated are:
Epilepsy surgery: If the brain region from which the seizure originates can be identified and that region does not carry a critical function, surgical intervention may be considered. In suitable patients, the success rate can reach as high as 80 percent.
Vagus nerve stimulation (VNS): A small device placed in the chest aims to reduce seizure frequency by stimulating the vagus nerve.
Ketogenic diet: Especially in childhood epilepsies, this high-fat, low-carbohydrate diet can be used as a supportive treatment. However, it must always be applied under expert supervision.
Neuromodulation methods: New technologies are being developed that aim to prevent seizure onset by sending low-intensity electrical stimuli to the brain.
When Is Medication Discontinued in Treatment?
As a general rule, after at least 2–4 seizure-free years and with the normalization of EEG findings, gradual drug tapering can be planned. The decision to discontinue medication should be made by evaluating the patient’s type of epilepsy, seizure history, and individual risk factors. In some types of epilepsy, lifelong drug use may be necessary.
What must absolutely not be done: abruptly stopping the medication or changing the dose without a doctor’s approval.
Conclusion
In conclusion, the “best epilepsy medication” is different for every patient. Correctly identifying the seizure type, evaluating the patient’s individual characteristics, and regularly monitoring the treatment are the cornerstones of successful epilepsy management. Epilepsy is not a disease to be feared or hidden; with the right treatment, the vast majority of patients can continue their normal lives.
If you are having seizures or have questions about your treatment, you should definitely consult a neurologist.
Author: Prof. Dr. Mehmet Şenoğlu
References:
Turkish Neurological Society, Epilepsy Diagnosis and Treatment Guidelines, 2021
ILAE (International League Against Epilepsy) Guidelines
World Health Organization Epilepsy Data
Disclaimer: This article has been prepared for general informational purposes and does not constitute personal medical advice; all decisions regarding epilepsy treatment must be made by a neurologist.