Drug Selection by Seizure Type
Focal Onset
- Carbamazepine, lamotrigine, levetiracetam
- Oxcarbazepine, lacosamide
- Any focal-spectrum drug appropriate
Generalized Tonic-Clonic
- Valproate, lamotrigine, levetiracetam
- Topiramate
- Broad-spectrum agents required
Absence
- Ethosuximide (pure absence)
- Valproate (mixed types)
- Avoid carbamazepine, phenytoin, gabapentin
Myoclonic
- Valproate first-line
- Levetiracetam alternative
- Avoid sodium channel blockers
Juvenile Myoclonic Epilepsy
- Valproate first-line
- Levetiracetam or lamotrigine if valproate not appropriate
Pregnancy
Figure 1 — Pregnancy Drug Selection (Gemini)
Preferred
- Lamotrigine — most data, lower teratogenic risk
- Levetiracetam — growing evidence, no major malformation signal
- Folic acid mandatory for all
Avoid When Possible
- Valproate — highest teratogenic risk (black box)
- Phenytoin — fetal hydantoin syndrome
- Carbamazepine — neural tube defects
- Topiramate — cleft palate and lip
Special Populations
Figure 2 — Population Drug Selection Table (Gemini)
Elderly
- Prefer lamotrigine, levetiracetam, gabapentin
- Avoid phenytoin (kinetics unreliable), phenobarbital (sedation), carbamazepine (interactions)
- Reduce doses for renal impairment
Neonates
- Phenobarbital first-line
- Levetiracetam increasingly used as alternative
- Seizures often from acute injury, not epilepsy
Children
- Match drug to syndrome
- Monitor behavioral effects (levetiracetam irritability, phenobarbital hyperactivity)
- Topiramate impairs learning — monitor school performance
Universal Rule
Match drug to seizure type first. Patient characteristics (pregnancy, age, comorbidities) then determine which appropriate drug is safest. No anti-seizure drug is completely safe in pregnancy — the goal is lowest effective dose of the drug with the lowest teratogenic risk that controls seizures.