Four questions that organise epilepsy care
Diagnosis and treatment are linked. Wise prescribing starts before the prescription.
Is the event an epileptic seizure?
Start with history and witness description. Consider syncope, functional/dissociative seizures, migraine, sleep disorders, movement disorders and acute medical causes.
If epileptic, what type?
Classify the seizure and epilepsy as accurately as possible. Focal versus generalized biology can materially change medicine choice.
What is the best first medicine for this person?
Match efficacy to seizure type while considering age, pregnancy potential, cognition, mood, weight, renal/hepatic function, interactions, adherence and lifestyle.
If needed, what is the best next step?
Before simply adding another drug, reassess diagnosis, adherence, classification, dose, interactions, provoking factors and whether drug-resistant epilepsy or a surgical pathway should be considered.
Investigate strategically
EEG, MRI and targeted laboratory/genetic testing answer different questions. Treat the patient, not an isolated test result.
Separate acute symptomatic seizures
A seizure provoked by an acute systemic or brain insult is not automatically epilepsy and may require a different duration of therapy.
Refer early when appropriate
Drug resistance, diagnostic uncertainty, pregnancy complexity, surgical candidacy and difficult syndromes warrant specialist or tertiary input.
Two practical rules
Divide before drugs. Classify first. Don't have favourites. Choose the medicine that fits the epilepsy and the person.
Open the medicine selection guideFramework adapted from Dr Balaji Kalband's ANZGMU 2026 presentation, “Seizures: What do I do?”, and updated to current ILAE terminology.