Epilepsies in children, young people and adults

Offer a choice of lamotrigine, levetiracetam or sodium valproate as first-line monotherapy for generalised tonic-clonic seizures. Follow the MHRA safety measures and precautionary advice for sodium valproate in box 2. If the first choice of treatment is unsuccessful, try another one of these options. If that is also unsuccessful, try the third option.

In January 2025, these were off-label uses of lamotrigine in children under 13 years and levetiracetam in adults and children. See NICE's information on prescribing medicines.

If monotherapy is unsuccessful in people with generalised tonic-clonic seizures, consider 1 of the following first-line add-on treatment options:

• clobazam

• lamotrigine

• levetiracetam

• perampanel

• sodium valproate (follow the MHRA safety measures and precautionary advice for sodium valproate in box 2)

• topiramate (do not use topiramate in women and girls of childbearing potential unless the conditions of the Pregnancy Prevention Programme are fulfilled).
  
  If the first choice is unsuccessful, consider the other first-line add-on options.
  
  In January 2025, this was an off-label use of some antiepileptic medication in children. See NICE's information on prescribing medicines.

If first-line add-on treatments tried are unsuccessful in people with generalised tonic-clonic seizures, consider 1 of the following second-line add-on treatment options:

• brivaracetam

• lacosamide

• phenobarbital

• primidone

• zonisamide.
  
  If the first choice is unsuccessful, consider the other second-line add-on options.
  
  In January 2025, these were off-label uses of brivaracetam in adults and children, lacosamide in children under 4 years, and zonisamide in adults and children. See NICE's information on prescribing medicines.

Be aware that the following antiseizure medications may exacerbate seizures in people with absence or myoclonic seizures, including in juvenile myoclonic epilepsy:

• carbamazepine

• gabapentin

• lamotrigine (for myoclonic seizures)

• oxcarbazepine

• phenytoin

• pregabalin

• tiagabine

• vigabatrin.

Consider lamotrigine or levetiracetam as first-line monotherapy for people with focal seizures. If the first choice is unsuccessful, consider the other of these options.

In January 2025, these were off-label uses of lamotrigine in children under 13 years, and levetiracetam in children and young people under 16 years. See NICE's information on prescribing medicines.

If first-line monotherapies are unsuccessful in people with focal seizures, consider 1 of the following second-line monotherapy options:

• carbamazepine

• oxcarbazepine

• zonisamide.
  
  If the first choice is unsuccessful, consider the other second-line monotherapy options.
  
  In January 2025, these were off-label uses of oxcarbazepine in children under 6 years, and zonisamide in children. See NICE's information on prescribing medicines.

If second-line monotherapies tried are unsuccessful in people with focal seizures, consider lacosamide as third-line monotherapy.

In January 2025, this was an off-label use of lacosamide in children under 2 years. See NICE's information on prescribing medicines.

If monotherapy is unsuccessful in people with focal seizures, consider 1 of the following first-line add-on treatment options:

• carbamazepine

• lacosamide

• lamotrigine

• levetiracetam

• oxcarbazepine

• topiramate (do not use topiramate in women and girls of childbearing potential unless the conditions of the Pregnancy Prevention Programme are fulfilled)

• zonisamide.
  
  If the first choice is unsuccessful, consider the other first-line add-on options.
  
  In January 2025, this was an off-label use of some antiepileptic medication in children. See NICE's information on prescribing medicines.

If first-line add-on treatments tried are unsuccessful in people with focal seizures, consider 1 of the following second-line add-on treatment options:

• brivaracetam

• cenobamate (in line with NICE's technology appraisal guidance on cenobamate for treating focal onset seizures in epilepsy)

• eslicarbazepine acetate

• perampanel

• pregabalin.
  
  If the first choice is unsuccessful, consider the other second-line add-on options.
  
  In January 2025, this was an off-label use of some antiepileptic medication in children. See NICE's information on prescribing medicines.

If second-line add-on treatments tried are unsuccessful in people with focal seizures, consider 1 of the following third-line add-on treatment options:

• phenobarbital

• phenytoin

• sodium valproate (follow the MHRA safety measures and precautionary advice for sodium valproate in box 2)

• tiagabine

• vigabatrin.
  
  If the first choice is unsuccessful, consider the other third-line add-on options.
  
  In January 2025, this was an off-label use of tiagabine in children under 12 years. See NICE's information on prescribing medicines.

Offer ethosuximide as first-line treatment for absence seizures.

If first-line treatment is unsuccessful, offer a choice of lamotrigine, levetiracetam or sodium valproate as second-line monotherapy or add-on treatment for absence seizures. Follow the MHRA safety measures and precautionary advice for sodium valproate in box 2. If the first choice of treatment is unsuccessful, try another one of these options as second-line monotherapy or add-on treatment. If that is also unsuccessful, try the third option as monotherapy or add-on treatment.

In January 2025, these were off-label uses of lamotrigine in children under 2 years and levetiracetam in adults and children. See NICE's information on prescribing medicines.

Be aware that the following antiseizure medications may exacerbate seizures in people with absence seizures:

• carbamazepine

• gabapentin

• oxcarbazepine

• phenobarbital

• phenytoin

• pregabalin

• tiagabine

• vigabatrin.

Consider a choice of lamotrigine, levetiracetam or sodium valproate as first-line treatment for absence seizures with other seizure types (or at risk of these). Follow the MHRA safety measures and precautionary advice for sodium valproate in box 2. If the first choice of treatment is unsuccessful, try another one of these options as monotherapy or add-on treatment. If that is also unsuccessful, try the third option as monotherapy or add-on treatment.

In January 2025, this was an off-label use of some antiepileptic medication in children. See NICE's information on prescribing medicines.

If first-line treatments tried are unsuccessful for absence seizures and other seizure types (or at risk of these), consider ethosuximide as a second-line add-on treatment.

Be aware that the following antiseizure medications may exacerbate seizures in people with absence seizures and other seizure types (or at risk of these):

• carbamazepine

• gabapentin

• oxcarbazepine

• phenobarbital

• phenytoin

• pregabalin

• tiagabine

• vigabatrin.

If a child under 4 years has myoclonic seizures, either seek guidance on treatment from or refer to a tertiary paediatric neurologist.

Offer a choice of levetiracetam or sodium valproate as first-line treatment for myoclonic seizures. Follow the MHRA safety measures and precautionary advice for sodium valproate in box 2. If the first choice of treatment is unsuccessful, try the other one of these options as monotherapy or add-on treatment.

In January 2025, this was an off-label use of levetiracetam as monotherapy. See NICE's information on prescribing medicines.

If first-line treatment is unsuccessful for myoclonic seizures, consider 1 of the following as monotherapy or add-on treatment options:

• brivaracetam

• clobazam

• clonazepam

• lamotrigine

• phenobarbital

• piracetam

• topiramate (do not use topiramate in women and girls of childbearing potential unless the conditions of the Pregnancy Prevention Programme are fulfilled)

• zonisamide.
  
  If the first choice is unsuccessful, consider any other of these options.
  
  In January 2025, this was an off-label use of some antiepileptic medication in children. See NICE's information on prescribing medicines.

Be aware that lamotrigine can occasionally exacerbate myoclonic seizures.

Do not use any of the following antiseizure medications in people with myoclonic seizures because they may exacerbate seizures:

• carbamazepine

• gabapentin

• oxcarbazepine

• phenytoin

• pregabalin

• tiagabine

• vigabatrin.

Ensure that people with a diagnosis of tonic or atonic seizures are assessed by a neurologist with expertise in epilepsy to:

• diagnose the syndrome if possible and

• advise on investigation and treatment.

Offer a choice of lamotrigine or sodium valproate as first-line treatment for tonic or atonic seizures. Follow the MHRA safety measures and precautionary advice for sodium valproate in box 2. If the first choice of treatment is unsuccessful, try the other one of these options as monotherapy or add-on treatment.

In January 2025, these were off-label uses of lamotrigine as monotherapy for children under 13 years, and as an add-on therapy for children under 2 years. See NICE's information on prescribing medicines.

If first-line treatment is unsuccessful for treating tonic or atonic seizures, consider 1 of the following as monotherapy or add-on treatment options:

• clobazam

• rufinamide

• topiramate (do not use topiramate in women and girls of childbearing potential unless the conditions of the Pregnancy Prevention Programme are fulfilled).
  
  If the first choice is unsuccessful, consider any other of these options.
  
  In January 2025, this was an off-label use of some antiepileptic medication. See NICE's information on prescribing medicines.

If second-line treatment is unsuccessful for tonic or atonic seizures in children, consider a ketogenic diet as an add-on treatment under the supervision of a ketogenic diet team.

If all other treatment options for tonic or atonic seizures are unsuccessful, consider felbamate as an add-on treatment under the supervision of a neurologist with expertise in epilepsy.

In January 2025, felbamate was not licensed for use in the UK. See NICE's information on prescribing medicines.

Be aware that the following antiseizure medications may exacerbate seizures in people with tonic or atonic seizures:

• carbamazepine

• gabapentin

• oxcarbazepine

• pregabalin

• tiagabine

• vigabatrin.

Offer a choice of lamotrigine, levetiracetam or sodium valproate as first-line treatment for idiopathic generalised epilepsies. Follow the MHRA safety measures and precautionary advice for sodium valproate in box 2. If the first choice of treatment is unsuccessful, try another one of these options as monotherapy or add-on treatment. If that is also unsuccessful, try the third option as monotherapy or add-on treatment.

In January 2025, these uses were off label: lamotrigine as monotherapy for children under 13 years and as an add-on therapy for children under 2 years, and levetiracetam as monotherapy in adults and children. See NICE's information on prescribing medicines.

If first-line treatments are unsuccessful for idiopathic generalised epilepsies, consider perampanel or topiramate as second-line add-on treatment options. If the first choice is unsuccessful, consider the other of these options. Do not use topiramate in women and girls of childbearing potential unless the conditions of the Pregnancy Prevention Programme are fulfilled.

In January 2025, these were off-label uses of perampanel for children under 7 years and topiramate for children under 2 years. See NICE's information on prescribing medicines.