Epilepsy accounts for approximately 15 per cent of the SCE Neurology exam — the single largest topic by question volume. NICE CG137 (The Epilepsies) and the ILAE 2017 classification are the primary references. This page summarises the high-yield content.
First seizure management
Not every first seizure requires anti-epileptic drug treatment. After a first unprovoked tonic-clonic seizure, NICE recommends urgent referral to a first seizure clinic (to be seen within two weeks). An EEG and brain MRI should be arranged. AED treatment should be discussed if the risk of recurrence is assessed as high — factors that increase recurrence risk include an epileptiform EEG, a structural brain lesion on MRI, a seizure occurring during sleep, or a prior history of myoclonic jerks or absences suggesting an established epilepsy syndrome.
If the risk of recurrence is low (a single unprovoked seizure with normal EEG and normal MRI in an adult), it is reasonable to defer treatment and monitor. The decision to start AEDs should be a shared decision between the clinician and the patient, taking into account the patient's driving status, occupation, and personal risk tolerance.
The exam tests the nuance that a first seizure does not automatically require treatment — candidates who select "start sodium valproate" for every first seizure scenario lose marks.
AED selection
AED selection is determined by seizure type and epilepsy syndrome. NICE CG137 provides clear first-line recommendations.
Focal seizures (with or without secondary generalisation): first-line is lamotrigine or levetiracetam. Carbamazepine and oxcarbazepine are alternatives. Sodium valproate is a further alternative but is restricted in women of childbearing potential.
Generalised tonic-clonic seizures: first-line is sodium valproate (in males and women not of childbearing potential) or lamotrigine (in women of childbearing potential). Levetiracetam is an alternative for both groups.
Absence seizures: first-line is ethosuximide or sodium valproate. Lamotrigine is an alternative but is less effective for absences than ethosuximide or valproate.
Myoclonic seizures: first-line is sodium valproate or levetiracetam. Lamotrigine may worsen myoclonus and should be avoided.
Juvenile myoclonic epilepsy: sodium valproate is the most effective treatment but is restricted in women. Levetiracetam and lamotrigine are alternatives, though lamotrigine may be less effective. Carbamazepine, oxcarbazepine, and phenytoin can worsen JME and must be avoided.
This last point — drugs that can worsen specific epilepsy syndromes — is heavily tested. Carbamazepine worsening absence and myoclonic seizures is a classic exam question.
Women and epilepsy
The management of epilepsy in women of childbearing potential is one of the highest-yield topics in the exam and has become increasingly prominent following the MHRA sodium valproate restrictions.
Sodium valproate: must not be used in women or girls of childbearing potential unless a Pregnancy Prevention Programme is in place and no suitable alternative exists. This is a regulatory requirement, not just a clinical preference. Valproate is associated with a 30 to 40 per cent risk of neurodevelopmental disorders and a 10 per cent risk of congenital malformations in exposed pregnancies.
Pre-conception counselling: all women with epilepsy should receive pre-conception counselling. Folic acid 5 mg daily (not 400 micrograms — the higher dose is specifically for women on AEDs) should be prescribed from before conception to at least 12 weeks of gestation.
AED adjustments in pregnancy: lamotrigine levels fall significantly during pregnancy due to increased hepatic metabolism. Monitoring of lamotrigine levels and dose adjustment may be required. Levetiracetam levels also fall but to a lesser degree.
Breastfeeding: most AEDs are compatible with breastfeeding. The exceptions are barbiturates and benzodiazepines, which can cause sedation in the infant.
Status epilepticus
Status epilepticus is defined as a continuous seizure lasting more than five minutes, or two or more seizures without recovery of consciousness between them. Management follows a stepwise protocol.
First-line (0 to 5 minutes): secure airway, high-flow oxygen, IV access, check blood glucose. Benzodiazepine (5 to 15 minutes): IV lorazepam 4 mg (repeated once after 10 minutes if seizures continue). If no IV access, buccal midazolam 10 mg or rectal diazepam 10 mg. Second-line (15 to 25 minutes): if seizures continue after two doses of benzodiazepine, give IV levetiracetam, IV phenytoin, or IV sodium valproate. NICE does not specify a preference between these three — the choice depends on the patient's existing AED therapy, comorbidities, and local protocol. Third-line (25+ minutes, refractory status): general anaesthesia with thiopental, propofol, or midazolam infusion. This requires ICU admission and intubation.
The exam tests the drug choices, doses, and the time thresholds for escalation. Know the lorazepam dose (4 mg IV, not 2 mg) and the point at which you escalate to second-line and third-line agents.
DVLA implications
Epilepsy has specific DVLA driving restrictions covered in detail in our dedicated DVLA driving rules guide. The key fact for epilepsy-related questions is that Group 1 requires 12 months seizure-free; Group 2 requires 10 years seizure-free and off all AEDs for 10 years.
iatroX's SCE Neurology bank includes extensive epilepsy content covering NICE CG137, ILAE 2017 classification, AED selection, women and epilepsy, status epilepticus, and DVLA rules. Epilepsy questions are tagged for focused practice. All included at £29 per month or £99 per year.