How to Find the Right Epilepsy Medication

Medically Reviewed by Christopher Melinosky, MD on January 07, 2020
4 min read

The goal in treating epilepsy is to control your seizures so you can focus on life again. Over the last 20 years, the number of treatment options has grown. Today, your doctor can choose from more than 20 medicines.

To find the right drug, your doctor will consider a few things, including:

  • The type of seizures you have
  • Other medical conditions you have
  • Other drugs you take
  • Your insurance coverage

Your medical history and tests like an EEG (electroencephalogram) and MRI (magnetic resonance imaging) can help your doctor learn what kind of seizures you're having.

"Some seizures start in just one part of the brain [focal onset seizures] and some start with the whole brain firing off at the same time [generalized onset seizures]," says Adam Hartman, MD, director of basic epilepsy research at the Johns Hopkins Children's Center. "We think about which medication is most likely to work for a particular patient's seizures."

Your other health conditions also matter. Some epilepsy drugs can interact with medicines you already take. Others serve double duty and can treat a second condition. For example, topiramate (Qudexy XR, Topamax, Trokendi XR) can help both seizures and migraine headaches. Lamotrigine (Lamictal) can treat epilepsy plus bipolar disorder.

The doctor will also consider which medicines your insurance will cover. Generic drugs usually cost less than brand name drugs. But do they work as well?

Generally, yes. The FDA requires a generic drug to have the same active ingredient, strength, and quality as its brand-name counterpart. Yet various generic versions of the same drug can differ from one another quite a bit.

Some big-chain drugstores switch generic drugs often to get the best prices, which means you may get bumped from one medicine to another. "We tell patients, if you want to go generic, you have to go to your pharmacy and say, 'Can you guarantee me the same generic?'" says Imad Najm, MD, director of the Cleveland Clinic Epilepsy Center.

After considering all of these things, your doctor will start you on a medicine. "Usually we start with a single drug at its lowest effective dose," Hartman says. "If someone's seizures are well controlled with a low dose of medication, that's the dose we use."

Once you're on a drug, you'll wait to see if your seizures improve. "To judge whether the medication is working, we need to look at seizure frequency," Najm says. If you have seizures every day, you should be able to tell within a month if the medicine has relieved them or made them less frequent. For seizures that come only once every few months, you'll have to stay on the medicine longer to see an effect.

About half of people will be seizure-free with the first drug they try. If your seizures don't get better or they only improve a little, your doctor will increase the dose, switch you to a new drug, or add a drug.

Another reason to switch drugs is if you can't tolerate the side effects, which can range from fatigue and stomachaches to mood changes. When Wendy Wolski's daughter, Devon, was diagnosed with epilepsy at age 6, her doctor started her on levetiracetam (Keppra, Spritam). But she didn't stay on the drug for long. "It turned my little girl into a monster," Wolski says. "She was very moody and irritable."

In general, newer epilepsy drugs like cenobamate (Xcopri), oxcarbazepine (Oxtellar XR, Trileptal), pregabalin (Lyrica), and topiramate (Topamax) cause fewer side effects than older drugs like carbamazepine (Carbatrol, Epitol, Equetro, Tegretol, Tegretol-XR), phenytoin (Dilantin, Dilantin Infatabs, Phenytek), or valproic acid (Depakene, Depakote, Stavzor). Yet any medicine can cause problems.

After trying one to three epilepsy drugs, about two-thirds of people find relief from their seizures. What if you're among the one-third of people whose seizures don't improve?

"After that the odds of success go down," Hartman says. "That's where we start thinking about alternative therapies."

Surgery, neurostimulation (an implanted device that disrupts abnormal electrical signals in the brain to stop seizures), and a ketogenic diet are all options if medicine hasn't been effective. You can also join a clinical trial to try a new epilepsy drug being studied.

To increase your odds of treatment success, take the drug exactly as prescribed. If you have any side effects, report them to your doctor -- don't just stop taking the medicine. "Remember that this is a partnership," Hartman says. "Every side effect is worthy to be discussed."

It can take some trial and error to find the treatment that strikes the right balance of seizure relief and side effects. Devon and her doctor had to try a few different drug combinations and doses.

Today, she takes valproic acid and lamotrigine, which seems to be working. "She's been seizure-free for a year and a half," Wolski says. "She's like a normal kid. She's the girl she'd be if she didn't have epilepsy."