Epilepsies: diagnosis and
`management
`
`Clinical guideline
`Published: 11 January 2012
`www.nice.org.uk/guidance/cg137
`
`© NICE 2021. All rights reserved. Subject to Notice of rights (https://www.nice.org.uk/terms-and-conditions#notice-of-
`rights). Last updated 12 May 2021
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`Epilepsies: diagnosis and management (CG137)
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`
`
`Your responsibility Your responsibility
`
`The recommendations in this guideline represent the view of NICE, arrived at after careful
`consideration of the evidence available. When exercising their judgement, professionals and
`practitioners are expected to take this guideline fully into account, alongside the individual needs,
`preferences and values of their patients or the people using their service. It is not mandatory to
`apply the recommendations, and the guideline does not override the responsibility to make
`decisions appropriate to the circumstances of the individual, in consultation with them and their
`families and carers or guardian.
`
`Local commissioners and providers of healthcare have a responsibility to enable the guideline to be
`applied when individual professionals and people using services wish to use it. They should do so in
`the context of local and national priorities for funding and developing services, and in light of their
`duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of
`opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a
`way that would be inconsistent with complying with those duties.
`
`Commissioners and providers have a responsibility to promote an environmentally sustainable
`health and care system and should assess and reduce the environmental impact of implementing
`NICE recommendations wherever possible.
`
`© NICE 2021. All rights reserved. Subject to Notice of rights (https://www.nice.org.uk/terms-and-
`conditions#notice-of-rights). Last updated 12 May 2021
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`Epilepsies: diagnosis and management (CG137)
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`
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`Contents Contents
`
`Overview ................................................................................................................................................................................ 8
`
`Who is it for? ...................................................................................................................................................................................... 8
`
`Introduction .......................................................................................................................................................................... 9
`
`Key priorities for implementation ................................................................................................................................11
`
`Diagnosis ............................................................................................................................................................................................. 11
`
`Management ...................................................................................................................................................................................... 11
`
`Prolonged or repeated seizures and convulsive status epilepticus ............................................................................. 11
`
`Special considerations for women and girls of childbearing potential ....................................................................... 12
`
`Review and referral ......................................................................................................................................................................... 12
`
`1 Guidance .............................................................................................................................................................................14
`
`1.1 Principle of decision making ................................................................................................................................................. 14
`
`1.2 Coping with epilepsy ............................................................................................................................................................... 14
`
`1.3 Information ................................................................................................................................................................................. 15
`
`1.4 Following a first seizure ......................................................................................................................................................... 18
`
`1.5 Diagnosis ...................................................................................................................................................................................... 19
`
`1.6 Investigations ............................................................................................................................................................................. 20
`
`1.7 Classification .............................................................................................................................................................................. 23
`
`1.8 Management ............................................................................................................................................................................... 24
`
`1.9 Pharmacological treatment .................................................................................................................................................. 24
`
`Sodium valproate ............................................................................................................................................................................. 25
`
`1.10 Referral for complex or refractory epilepsy ................................................................................................................ 51
`
`1.11 Psychological interventions ............................................................................................................................................... 53
`
`1.12 Ketogenic diet ......................................................................................................................................................................... 53
`
`1.13 Vagus nerve stimulation (VNS) ........................................................................................................................................ 53
`
`1.14 Prolonged or repeated seizures and convulsive status epilepticus .................................................................. 54
`
`1.15 Women and girls with epilepsy ......................................................................................................................................... 57
`
`© NICE 2021. All rights reserved. Subject to Notice of rights (https://www.nice.org.uk/terms-and-
`conditions#notice-of-rights). Last updated 12 May 2021
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`1.16 Children, young people and adults with learning disabilities (also see the sections on pregnancy
`and young people with epilepsy) ................................................................................................................................................ 62
`
`1.17 Young people with epilepsy (also see the section on women and girls with epilepsy) ............................... 64
`
`1.18 Older people with epilepsy ................................................................................................................................................ 65
`
`1.19 Children, young people and adults from black and minority ethnic groups ................................................... 66
`
`1.20 Review ........................................................................................................................................................................................ 66
`
`2 Implementation ...............................................................................................................................................................68
`
`3 Research recommendations .......................................................................................................................................69
`
`3.1 Newly diagnosed seizures (focal and generalised) – monotherapy ...................................................................... 69
`
`3.2 Epilepsy syndromes ................................................................................................................................................................. 70
`
`3.3 Infantile spasms ......................................................................................................................................................................... 70
`
`3.4 Treatment of convulsive status epilepticus (that is, not just refractory) ............................................................ 71
`
`3.5 AEDs and pregnancy ............................................................................................................................................................... 72
`
`Appendix C: Outline care algorithms .........................................................................................................................74
`
`Appendix D: Differential diagnosis of epilepsy in children, young people and adults .............................75
`
`Appendix E: Pharmacological treatment ...................................................................................................................76
`
`Appendix F: Protocols for treating convulsive status epilepticus in adults and children (adults
`published in 2004 and children published in 2011) ...............................................................................................77
`
`Guidelines for treating convulsive status epilepticus in children (published in 2011) ......................................... 80
`
`Non-convulsive status epilepticus in adults and children (2004 guideline) ............................................................. 81
`
`Appendix G: Terms used in this guideline ..................................................................................................................83
`
`Absence seizure ............................................................................................................................................................................... 83
`
`Adherence .......................................................................................................................................................................................... 83
`
`Adjunctive treatment .................................................................................................................................................................... 84
`
`Aetiology ............................................................................................................................................................................................ 84
`
`Anti-epileptic drug (AED) ............................................................................................................................................................. 84
`
`Atonic seizure ................................................................................................................................................................................... 84
`
`Attack ................................................................................................................................................................................................... 84
`
`Baseline ............................................................................................................................................................................................... 84
`
`© NICE 2021. All rights reserved. Subject to Notice of rights (https://www.nice.org.uk/terms-and-
`conditions#notice-of-rights). Last updated 12 May 2021
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`Benign epilepsy with centrotemporal spikes (BECTS) ..................................................................................................... 84
`
`Carer ..................................................................................................................................................................................................... 85
`
`Childhood absence epilepsy ....................................................................................................................................................... 85
`
`Clinical presentation ...................................................................................................................................................................... 85
`
`Clinician ............................................................................................................................................................................................... 85
`
`Comorbidity ...................................................................................................................................................................................... 85
`
`Concordance ..................................................................................................................................................................................... 85
`
`Continuous spike and wave during slow sleep (CSWS) .................................................................................................... 85
`
`Convulsive status epilepticus ..................................................................................................................................................... 86
`
`Dosage ................................................................................................................................................................................................. 86
`
`Dravet syndrome ............................................................................................................................................................................. 86
`
`Electrocardiogram (ECG) ............................................................................................................................................................. 86
`
`Electroencephalogram (EEG) ..................................................................................................................................................... 86
`
`Epilepsy ............................................................................................................................................................................................... 86
`
`Epilepsy syndrome .......................................................................................................................................................................... 86
`
`Epileptic seizure ............................................................................................................................................................................... 87
`
`Focal seizure ...................................................................................................................................................................................... 87
`
`Generalised seizure ........................................................................................................................................................................ 87
`
`Generalised tonic–clonic (GTC) seizure ................................................................................................................................. 87
`
`Genetic (with reference to epilepsy) ....................................................................................................................................... 87
`
`Ictal phenomenology ..................................................................................................................................................................... 87
`
`Idiopathic ............................................................................................................................................................................................ 87
`
`Idiopathic generalised epilepsy (IGE) ...................................................................................................................................... 88
`
`Indication (specific) ......................................................................................................................................................................... 88
`
`Infantile spasms ............................................................................................................................................................................... 88
`
`Intervention ....................................................................................................................................................................................... 88
`
`Juvenile absence epilepsy ............................................................................................................................................................ 88
`
`Juvenile myoclonic epilepsy (JME) ........................................................................................................................................... 88
`
`© NICE 2021. All rights reserved. Subject to Notice of rights (https://www.nice.org.uk/terms-and-
`conditions#notice-of-rights). Last updated 12 May 2021
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`Ketogenic diet ................................................................................................................................................................................... 89
`
`Landau–Kleffner syndrome (LKS) ............................................................................................................................................ 89
`
`Late-onset childhood occipital epilepsy (Gastaut type) .................................................................................................. 89
`
`Lennox–Gastaut syndrome ......................................................................................................................................................... 89
`
`Monotherapy .................................................................................................................................................................................... 89
`
`Myoclonic-astatic epilepsy (MAE) ............................................................................................................................................ 89
`
`Myoclonic seizures ......................................................................................................................................................................... 89
`
`Neurological deficit ........................................................................................................................................................................ 90
`
`Non-convulsive status epilepticus ........................................................................................................................................... 90
`
`Non-epileptic attack disorder (NEAD) ................................................................................................................................... 90
`
`Older people ...................................................................................................................................................................................... 90
`
`Panayiotopoulos syndrome ........................................................................................................................................................ 90
`
`Pharmacokinetics ............................................................................................................................................................................ 90
`
`Polypharmacy ................................................................................................................................................................................... 90
`
`Polytherapy ....................................................................................................................................................................................... 91
`
`Prognosis ............................................................................................................................................................................................ 91
`
`Provocation techniques ................................................................................................................................................................ 91
`
`Quality of life ..................................................................................................................................................................................... 91
`
`Refractory status epilepticus ..................................................................................................................................................... 91
`
`Secondarily generalised seizure ................................................................................................................................................ 91
`
`Simple and complex partial epileptic seizures ..................................................................................................................... 91
`
`Specialist (as used in this guideline) ......................................................................................................................................... 92
`
`Sudden unexpected (or unexplained) death in epilepsy (SUDEP) ............................................................................... 92
`
`Syncope ............................................................................................................................................................................................... 92
`
`Tertiary epilepsy specialist .......................................................................................................................................................... 92
`
`Tertiary service ................................................................................................................................................................................ 92
`
`Tonic seizure ...................................................................................................................................................................................... 92
`
`Tonic–clonic seizure ....................................................................................................................................................................... 92
`
`© NICE 2021. All rights reserved. Subject to Notice of rights (https://www.nice.org.uk/terms-and-
`conditions#notice-of-rights). Last updated 12 May 2021
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`Finding more information and committee details ..................................................................................................94
`
`Update information ............................................................................................................................................................95
`
`© NICE 2021. All rights reserved. Subject to Notice of rights (https://www.nice.org.uk/terms-and-
`conditions#notice-of-rights). Last updated 12 May 2021
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`Epilepsies: diagnosis and management (CG137)
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`This guideline replaces CG20, TA76 and TA79.
`
`This guideline is the basis of QS26 and QS27.
`
`
`
`Overview Overview
`
`The guideline covers diagnosing, treating and managing epilepsy and seizures in children, young
`people and adults in primary and secondary care. It offers best practice advice on managing
`epilepsy to improve health outcomes so that people with epilepsy can fully participate in daily life.
`
`MHRA advice on antiepileptic drugs in pregnancy:MHRA advice on antiepileptic drugs in pregnancy: In May 2021, we reviewed and amended
`
`recommendations on carbamazepine, gabapentin, lamotrigine, levetiracetam, oxcarbazepine,
`phenobarbital, phenytoin, pregabalin, topiramate and zonisamide in line with Medicines and
`Healthcare products Regulatory Agency (MHRA) updated safety advice on antiepileptic drugs in
`pregnancy.
`
`MHRA advice on valproate:MHRA advice on valproate: We have amended recommendations in line with the MHRA guidance
`
`on valproate use by women and girls. Valproate must not be used in women and girls of
`childbearing potential (including young girls who are likely to need treatment into their
`childbearing years), unless other options are unsuitable and the pregnancy prevention programme
`is in place. The MHRA has published temporary advice on the valproate pregnancy prevention
`programme during the COVID-19 pandemic.
`
`
`
`Who is it for? Who is it for?
`
`• Healthcare professionals
`
`• People who work in occupational health services, social services, educational services and the
`voluntary sector
`
`• Children, young people and adults with epilepsy and their families and carers
`
`This guideline updates and replaces NICE guideline CG20 (October 2004).
`
`© NICE 2021. All rights reserved. Subject to Notice of rights (https://www.nice.org.uk/terms-and-
`conditions#notice-of-rights). Last updated 12 May 2021
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`Introduction Introduction
`
`This guidance updates and replaces NICE guideline CG20. This guidance also updates and
`replaces NICE technology appraisal guidance 76 (2004) and NICE technology appraisal
`guidance 79 (2004).
`
`New recommendations have been added for the pharmacological treatment of people with
`epilepsy, including the use of ketogenic diet (see about this guideline for details).
`
`Epilepsy is a common neurological disorder characterised by recurring seizures. Different types of
`epilepsy have different causes. Accurate estimates of incidence and prevalence are difficult to
`achieve because identifying people who may have epilepsy is difficult. Epilepsy has been estimated
`to affect between 362,000 and 415,000 people in England. In addition, there will be further
`individuals, estimated to be 5–30%, so amounting to up to another 124,500 people, who have been
`diagnosed with epilepsy, but in whom the diagnosis is incorrect. Incidence is estimated to be 50 per
`100,000 per year and the prevalence of active epilepsy in the UK is estimated to be 5–10 cases per
`1000. Two-thirds of people with active epilepsy have their epilepsy controlled satisfactorily with
`anti-epileptic drugs (AEDs). Other approaches may include surgery. Optimal management
`improves health outcomes and can also help to minimise other, often detrimental, impacts on social,
`educational and employment activity. The previous NICE guideline on epilepsy stated that the
`annual estimated cost of established epilepsies was £2 billion (direct and indirect costs).
`
`Newer and more expensive AEDs are now being prescribed, and with an increase in treatment
`costs likely in coming years it is essential to ensure that AEDs with proven clinical and cost
`effectiveness are identified. The evidence used to develop the previous NICE guideline for epilepsy
`and related technology appraisals showed no difference in effectiveness between newer and older
`AEDs, or between the newer drugs (as monotherapy) for seizure control. However, a recent large
`multicentre trial (the SANAD trial) evaluating newer drugs in newly diagnosed epilepsy (accepting
`some limitations) suggested that sodium valproate should be the drug of choice in generalised and
`unclassifiable epilepsies, and lamotrigine in focal epilepsies. It was therefore considered necessary
`to review new evidence regarding AEDs within an update of NICE guideline CG20 (which was
`published in 2004).
`
`The guideline will assume that prescribers will use a drug's summary of product characteristics to
`inform decisions made with individual patients.
`
`© NICE 2021. All rights reserved. Subject to Notice of rights (https://www.nice.org.uk/terms-and-
`conditions#notice-of-rights). Last updated 12 May 2021
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`Epilepsies: diagnosis and management (CG137)
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`This guideline recommends some drugs for indications for which they do not have a UK marketing
`authorisation at the date of publication, if there is good evidence to support that use. Where
`recommendations have been made for the use of drugs outside their licensed indications,
`information on this off-label use has been added to the recommendations.
`
`© NICE 2021. All rights reserved. Subject to Notice of rights (https://www.nice.org.uk/terms-and-
`conditions#notice-of-rights). Last updated 12 May 2021
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`Epilepsies: diagnosis and management (CG137)
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`Key priorities for implementation Key priorities for implementation
`
`The following recommendations have been identified as priorities for implementation.
`
`
`
`Diagnosis Diagnosis
`
`• All children, young people and adults with a recent onset suspected seizure should be seen
`urgently by a specialist (as used in this guideline). This is to ensure precise and early diagnosis
`and initiation of therapy as appropriate to their needs. The Guideline Development Group
`
`considered that 'urgently' meant being seen within 2 weeks. [2004] [2004]
`
`
`
`Management Management
`
`• Healthcare professionals should adopt a consulting style that enables the child, young person
`or adult with epilepsy, and their family and/or carers as appropriate, to participate as partners
`in all decisions about their healthcare, and take fully into account their race, culture and any
`
`specific needs. [2004] [2004]
`
`• All children, young people and adults with epilepsy should have a comprehensive care plan that
`is agreed between the person, their family and/or carers as appropriate, and primary and
`
`secondary care providers. [2004] [2004]
`
`• The AED (anti-epileptic drug) treatment strategy should be individualised according to the
`seizure type, epilepsy syndrome, co-medication and co-morbidity, the child, young person or
`adult's lifestyle, and the preferences of the person, their family and/or carers as appropriate.
`
`[2004] [2004]
`
`Prolonged or repeated seizures and Prolonged or repeated seizures and convulsive status convulsive status
`
`
`
`
`epilepticus epilepticus
`
`• Only prescribe buccal midazolam or rectal diazepam for use in the community for children,
`young people and adults who have had a previous episode of prolonged or serial convulsive
`
`seizures. [2012] [2012]
`
`In January 2012, this was an off-label use of diazepam (see the British national formulary
`[BNF] or the British national formulary for children [BNFC] for details). See NICE's information
`on prescribing medicines.
`
`© NICE 2021. All rights reserved. Subject to Notice of rights (https://www.nice.org.uk/terms-and-
`conditions#notice-of-rights). Last updated 12 May 2021
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`Epilepsies: diagnosis and management (CG137)
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`• Administer buccal midazolam as first-line treatment in children, young people and adults with
`prolonged or repeated seizures in the community. Administer rectal diazepam if preferred or if
`buccal midazolam is not available. If intravenous access is already established and
`
`resuscitation facilities are available, administer intravenous lorazepam. [2012] [2012]
`
`In January 2012, this was an off-label use of diazepam (see the BNF or BNFC for details). See
`NICE's information on prescribing medicines.
`
`Special considerations for women and girls of Special considerations for women and girls of
`
`
`childbearing potential childbearing potential
`
`• Women and girls with epilepsy and their partners, as appropriate, must be given accurate
`information and counselling about contraception, conception, pregnancy, caring for children,
`
`breastfeeding and menopause. [2004] [2004]
`
`• Discuss with women and girls of childbearing potential (including young girls who are likely to
`need treatment into their childbearing years), and their parents and/or carers if appropriate,
`the risk of AEDs causing malformations and possible neurodevelopmental impairments in an
`unborn child.
`
`Assess the risks and