NICE guideline on AEDs
NICE produces guidance for the treatment and management of
health conditions in England and Wales. Its guidance on epilepsy
includes recommendations for the drug treatment of different
types of epilepsy and seizures.
about NICE
NICE is the National Institute for Health and Care
Excellence. It is an independent organisation that
provides national guidance, recommendations and
quality standards to improve health and social care
services in England.
NICEs clinical guidelines recommend how specific
health conditions should be diagnosed, treated and
managed. Clinical guidelines take into account best
practice and evidence-based research to develop
recommendations.
The clinical guideline for epilepsy (CG137) is called
The epilepsies: the diagnosis and management of
the epilepsies in adults and children in primary and
secondary care. Part of this guideline covers the
recommended anti-epileptic drugs (AEDs) for treating
different types of seizures.
This factsheet looks at the treatment the epilepsy
guideline recommends for particular types of seizures.
For more detailed information on the guideline
for epilepsy visit www.nice.org.uk/guidance/cg137/
notes
The AEDs listed in the tables on the following pages
are listed by their generic name (the name of the active
ingredient).
The titles of the rows and what they mean
First line treatment this refers to a drug that is tried
first and usually used on its own. If more than one
AED is listed in this row, one AED will be chosen and
tried on its own first. If it does not work, the another
may be tried, or a drug from the alternative first line
drug list might be used.
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factsheet
29
Alternative first line treatment this is the second
round of AEDs that are tried. Like the first line
treatment they are usually tried on their own,
although sometimes combinations might be used.
Adjunctive treatment (or add-on treatment)
these are AEDs that might be added to a first line
treatment (so are used in combination). This happens
if a first line treatment does not control the seizures
or is not tolerated (for example, has side effects which
means that the person cannot continue on that AED).
Action if adjunctive treatment is not effective
or tolerated this is guidance on what to do if
adjunctive treatment does not work. In some situations
referral back to a neurologist, or on to specialist
neurological services (or tertiary services), might be
needed. It may be that the persons diagnosis needs
to be looked at, or a more specialist combination of
treatment is needed.
Cautions this includes situations where extra care
is needed when prescribing AEDs. Some AEDs can
have specific side effects, or there may be AEDs that
make some seizure types worse rather than better.
Tertiary epilepsy services these are specialist
services in hospitals or units that focus on specific
conditions. You have to be referred to tertiary services,
usually from secondary care (your local hospital).
treatment of focal seizures
Treatment of focal seizures in children, young people and adults.

First line treatment carbamazepine, lamotrigine

Alternative first line treatment
Cautions
Adjunctive treatment (if first line
treatment is not effective or not tolerated)
Cautions
Action if adjunctive treatment is not
effective or not tolerated
levetiracetam, oxcarbazepine, sodium valproate
be aware of potential effect of sodium valproate in pregnancy
carbamazepine, clobazam, gabapentin, lamotrigine, levetiracetam,
oxcarbazepine, sodium valproate, topiramate
be aware of potential effect of sodium valproate in pregnancy
consider referral to tertiary epilepsy services (where other AEDs may
be tried)

treatment of generalised tonic clonic seizures

Treatment of generalised tonic clonic seizures in children, young people and adults.

First line treatment sodium valproate, lamotrigine (if sodium valproate is not suitable)
Cautions be aware of potential effect of sodium valproate in pregnancy.
If the person has myoclonic seizures or may have juvenile myoclonic
epilepsy lamotrigine may worsen myoclonic seizures
Alternative first line treatment carbamazepine, oxcarbazepine
Cautions be aware that these drugs may worsen myoclonic or absence seizures
Adjunctive treatment (if first line clobazam, lamotrigine, levetiracetam, sodium valproate, topiramate
treatment is not effective or not tolerated)
Cautions be aware of potential effect of sodium valproate in pregnancy. If the
person also has absences or myoclonic seizures, or may have juvenile
myoclonic epilepsy do not offer carbamazepine, gabapentin,
oxcarbazepine, phenytoin, pregabalin, tiagabine or vigabatrin

treatment of absence seizures

Treatment of absence seizures in children, young people and adults.

First line treatment
Cautions
Alternative first line treatment
Adjunctive treatment (if first line
treatment is not effective or not tolerated)
Cautions
Action if adjunctive treatment is not
effective or not tolerated
Cautions
ethosuximide, sodium valproate (offer first if additional tonic clonic
seizures are likely)
be aware of potential effect of sodium valproate in pregnancy
lamotrigine
consider a combination of ethosuximide, lamotrigine or sodium valproate
be aware of potential effect of sodium valproate in pregnancy
consider referral to tertiary epilepsy services (where other AEDs may
be tried)
do not offer carbamazepine, gabapentin, oxcarbazepine, phenytoin,
pregabalin, tiagabine or vigabatrin

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 factsheet 29
treatment of myoclonic seizures
Treatment of myoclonic seizures in children, young people and adults.

First line treatment sodium valproate

Cautions be aware of potential effect of sodium valproate in pregnancy
Alternative first line treatment levetiracetam, topiramate
Cautions be aware that topiramate has poorer side effects than sodium valproate
or levetiracetam
Adjunctive treatment (if first line levetiracetam, sodium valproate, topiramate
treatment is not effective or not tolerated)
Cautions be aware of potential effect of sodium valproate in pregnancy
Action if adjunctive treatment is not consider referral to tertiary epilepsy services (where other AEDs may
effective or not tolerated be tried)
Cautions do not offer carbamazepine, gabapentin, oxcarbazepine, phenytoin,
pregabalin, tiagabine or vigabatrin

treatment of tonic and atonic seizures

Treatment of tonic and atonic seizures in children, young people and adults.

First line treatment sodium valproate

Cautions be aware of potential effect of sodium valproate in pregnancy
Adjunctive treatment (if first line lamotrigine
treatment is not effective or not tolerated)
Action if adjunctive treatment is not consider referral to tertiary epilepsy services (where other AEDs may
effective or not tolerated be tried)
Cautions do not offer carbamazepine, gabapentin, oxcarbazepine, pregabalin,
tiagabine or vigabatrin

For information on the treatment of prolonged or repeated seizures, drug treatment by epilepsy syndrome,
and more about the licensing indications of the anti-epileptic drugs listed here, please see the full NICE guideline,
appendix E: pharmacological treatment.
See www.nice.org.uk/guidance/CG137/chapter/Appendix-E-Pharmacological-treatment

All information in the tables on this factsheet is taken from The epilepsies: the diagnosis and management of the
epilepsies in adults and children in primary and secondary care, NICE guideline (CG137), NICE, 2012.
For more information visit www.nice.org.uk/guidance/cg137/

Epilepsy Society August 2014

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