Epilepsy is a common disease with a complex range of aetiological factors; this is mirrored by the diverse classification systems in use. This article considers current supportive, pharmacological and surgical management in the context of epilepsy classification and casts a critical eye towards the possible contributions of new drug discoveries, pharmacogenetic and neurosurgical developments in the future management of epilepsy. Introduction A seizure is defined as a transient occurrence of signs and/or symptoms due to abnormal excessive or synchronous neuronal activity in the brain. Epilepsy is a disorder of the brain that is clinically defined. The international league against epilepsy (ILAE) definition requires an enduring predisposition to generate epileptic seizures that are not provoked by other illness. The definition also requires the occurrence of at least one epileptic seizure but most clinicians require two or more before labelling a patient as epileptic 1 .The prevalence of epilepsy is common both world wide and in the UK. It affects around 45 million people worldwide, this equates to a lifetime risk of around 3% 2 . The classification of epilepsy is notoriously difficult and mirrors the diverse aetiology and polygenicity of different types of epilepsy. The most widely accepted and clinically useful classification is that produced by the ILAE, this attempts to define an individual’s particular clinical manifestation of epilepsy into a distinct group based on seizure type or seizure syndrome 3 . Accurate classification is important for determining aetiology, pathology, research themes, appropriate treatment and prognostic prediction 4 .The treatment of epilepsy is (or arguably should be) inseparably bound to the underlying cause. In the majority of cases this is still unknown and ergo labelled as ‘idiopathic’, however there are a significant proportion (up to a third) that are due to identifiable precipitants. Common known causes include cerebrovascular, ischaemic or haemorrhagic events, trauma, malignancy, infections, neurodegenerative diseases or toxins 5 . It is important to identify these cases as they may not fulfil the diagnostic criteria of epilepsy and there may be specific and sometimes curative treatments that will often differ markedly from the idiopathic varieties.This article will consider current treatments of epilepsy including supportive and pharmacological management. We will briefly consider drug initiation and choice in epilepsy, then for each of the commonest seizure types we will look in more detail at one popular pharmacological agent. An analysis of the current role and efficacy of curative and palliative surgical intervention will follow. The essay will conclude by looking at where future advances in epilepsy treatment may come from. This will include an analysis of the potential roles of new drug discoveries, pharmacogenetics and targeted neurosurgical developments. Current treatments of idiopathic epilepsy Supportive managementThe management of epilepsy has become a multidisciplinary effort that is patient centred and holistic in its ethos. It is important not to forget the importance of allied health professionals and social support in the treatment of epilepsy. Epilepsy is not just a physical disease, the social implications are extremely important in a patient’s quality of life and the role of the wider health care team including psychological support and epilepsy nurse specialists are well established in patient care. Simple social measures such as providing free bus passes for patients unable to drive can have a profound impact on quality of life. The National Service Framework for Long-Term (neurological) medical conditions along with the National Institute for Health and Clinical Excellence (NICE) set out an overview for the standard of care in the United Kingdom for management of epilepsy 2, 6-8 .This review will mainly focus on the pharmacological and surgical management of epileps
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