Treating generalised tonic-clonic seizures

This page covers the single and add-on anti-seizure medication options for treating generalised tonic-clonic seizures.

Single anti-seizure medication options: group A

Sodium valproate (Epilim and other brand names) is the first single anti-seizure medication to be tried for generalised tonic-clonic seizures in:

• Boys and men
• Girls under 10 who aren’t likely to need treatment when they’re old enough to have children
• Women who can’t have children

However, there are new rules that apply to valproate treatments (see more information below). The treatment recommendations from NICE (the National Institute for Health and Care Excellence) that relate to valproate are currently being reviewed.

If sodium valproate doesn’t work, the following can be tried as a single anti-seizure medication:

• Lamotrigine (Lamictal and other brand names) or
• Levetiracetam (Keppra and other brand names)

If the first choice doesn’t work, and the diagnosis of epilepsy remains, then the second option will be tried.

Single anti-seizure medication options: group B 

For women and girls who can have children, including young girls likely to need treatment when they’re old enough to have children, the following anti-seizure medications can be tried:

• Lamotrigine (Lamictal and other brand names) or
• Levetiracetam (Keppra and other brand names)

If the first choice doesn’t work, and the diagnosis of epilepsy remains, then the second option will be tried.

Sodium valproate (Epilim) should not be tried as a first single anti-seizure medication for women and girls who can have children, including young girls likely to need treatment when they’re old enough to have children, unless: 

• Other treatments don’t work
• The benefits and risks have been fully discussed, including the risks to an unborn child
• The likelihood of pregnancy has been taken into account and a pregnancy prevention programme is in place, if appropriate

There are new rules that apply to valproate treatments (see more information above). The treatment recommendations from NICE (the National Institute for Health and Care Excellence) that relate to valproate are currently being reviewed.

Switching from the first to second single anti-seizure medication

During the switch from the first single anti-seizure medication to the second option:

• The dose of the first anti-seizure medication remains the same while the dose of the second is increased slowly
• If the second anti-seizure medication works, the dose of the first will be slowly tapered off

• If the second anti-seizure medication doesn’t work, the dose will be slowly tapered off and a third option considered

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First add-on anti-seizure medication options

If first or second single anti-seizure medications don’t work, then one of the following can be tried as an add-on treatment:

• Clobazam (Frisium, Onfi and other brand names)
• Lamotrigine (Lamictal and other brand names)
• Levetiracetam (Keppra and other brand names)
• Perampanel (Fycompa)
• Sodium valproate (Epilim and other brand names) – access to this treatment is limited, see more information above
• Topiramate (Topamax and other brand names)

If the first choice doesn’t work as an add-on treatment, then one of the others will be tried.

Second add-on anti-seizure medication options

If none of the above first add-on anti-seizure medications work, then the following can be tried:

• Brivaracetam (Briviact)
• Lacosamide (Vimpat and other brand names)
• Phenobarbital (Luminal and other brand names) 
• Primidone (Mysoline)
• Zonisamide (Zonegran and other brand names)

If the first one tried doesn’t work as an add-on treatment, then one of the others will be tried. 

Sodium valproate (Epilim and other brand names) should not be tried as an add-on treatment for women and girls who can have children, including young girls likely to need treatment when they’re old enough to have children, unless:

• Other treatments don’t work
• The benefits and risks have been fully discussed, including the risks to an unborn child
• The likelihood of pregnancy has been taken into account and a pregnancy prevention programme is in place, if appropriate

There are new rules that apply to valproate treatments (see more information above). The treatment recommendations from NICE (the National Institute for Health and Care Excellence) that relate to valproate are currently being reviewed.

Switching to using add-on anti-seizure medications

When starting an add-on treatment, the dose will be managed carefully and reviewed frequently.

This will include monitoring for side effects such as feeling sedated.

If add-on treatments don’t reduce seizures, epilepsy specialists will aim for the combination of anti-seizure medications that is the most effective while and has tolerable side effects.

Epilepsy specialists will discuss with the person, and their family or carers, as appropriate, the benefits of taking as few medicines as possible for seizure freedom or control.

Anti-seizure medications that may make seizures worse

In people with absence or myoclonic seizures, including in juvenile myoclonic epilepsy, the following anti-seizure medications may make seizures worse:

• Carbamazepine (Tegretol and other brand names)
• Gabapentin (Neurontin and other brand names)
• Lamotrigine (Lamictal and other brand names) for myoclonic seizures
• Oxcarbazepine (Trileptal and other brand names)
• Phenytoin (Dilantin and other brand names)
• Pregabalin (Lyrica and other brand names)
• Tiagabine (Gabitril)
• Vigabatrin (Sabril)

Find out more about Anti-seizure medications, contraception and pregnancy.