Focal epilepsy
Epilepsy with focal-onset seizures. Foundation: antiepileptic drugs (levetiracetam, lamotrigine, oxcarbazepine, carbamazepine, etc.); pharmacoresistant disease may require surgery.
ICD-10 G40.29 drugs
Also known as: Partial epilepsy
Drugs used for this condition
- ACarbamazepineFirst line · Antiepileptics. Carboxamide derivativesCarbamazepine and oxcarbazepine are first-line drugs for focal epilepsy in adults and children. NICE NG217 2022 recommends carbamazepine or lamotrigine as first choice for focal seizures. ILAE and Russian clinical guidelines align with this. The drug reduces seizure frequency by more than 50% in 60–70% of patients with focal epilepsy.
- ALacosamideFirst line · Antiepileptic – selective sodium channel modulatorFirst-line in focal epilepsy in adults and children over 4 per ILAE 2017 and the Spanish SEN 2024 alongside lamotrigine and levetiracetam. Starting dose 50 mg twice daily, titrated to 200–400 mg/day. In women of reproductive age, advantageous over carbamazepine and phenytoin because it does not induce CYP – does not reduce oral contraceptive or other drug efficacy.
- ALamotrigineFirst line · Antiepileptic with dual mechanismFirst-line in focal epilepsy in adults and adolescents from 13 years (NICE NG217, 2022; SANAD II trial) alongside levetiracetam; in children 2–12 years it is used as add-on therapy. Starting dose 25 mg once daily for 2 weeks, titrated to 100–400 mg daily. Particularly suitable in women of reproductive age – the lowest teratogenic potential among classic antiepileptics (malformation risk 2.5% vs 6–10% with valproate).
- ALevetiracetamFirst line · Antiepileptics (other)First-line for focal epilepsy in adults and children per NICE NG217 2022 and AAN/AES 2018 (a free choice alongside lamotrigine). Start 250–500 mg twice daily; target 1000–3000 mg daily. In the head-to-head SANAD II trial (2021), levetiracetam was worse than lamotrigine for seizure control, so lamotrigine is often preferred, including on cost-effectiveness. Levetiracetam is pharmacologically convenient (minimal drug interactions, no hepatic enzyme induction, no weight gain), but in some patients it causes irritability, mood swings, and behavioral changes, with a risk of suicidal ideation, so mood should be monitored.
- AZonisamideSecond line · Antiepileptic with multiple mechanismsSecond-line in focal epilepsy in adults and children over 6, as monotherapy or combination per ILAE 2017 and SEN 2024. First-line is lamotrigine, levetiracetam, lacosamide. Starting dose 50 mg once daily, titrated to 300–500 mg daily. Long half-life provides stable concentration.
- BClobazamAdd-on therapy · 1,5-benzodiazepine antiepilepticAdjunct in focal epilepsy in adults and children over 6 not controlled by monotherapy. ILAE 2017 and the Spanish SEN 2024 consensus place lamotrigine, levetiracetam, and lacosamide as first-line. Clobazam is added as a third or fourth agent. Standard starting dose 5–10 mg once daily at bedtime, titrated to 20–60 mg/day. Also used in Lennox–Gastaut and Dravet syndromes in children.
- BEslicarbazepine acetateThird line · Antiepileptic, carboxamide derivativeSecond-line in focal epilepsy in adults and adolescents over 6, as monotherapy or in combination. ILAE 2017 and the Spanish SEN 2024 consensus place lamotrigine, levetiracetam, and lacosamide as first-line. Eslicarbazepine is used when carbamazepine or oxcarbazepine (same class) are inadequate or intolerable – tolerability is better, with less hyponatremia and fewer skin reactions. Standard starting dose 400 mg once daily, titrated to 800–1200 mg.
- BPhenobarbitalThird line · Antiepileptics. BarbituratesPhenobarbital retains efficacy in focal and generalized epilepsy in adults. NICE NG217 and ILAE do not list phenobarbital as first-line due to pronounced sedative and cognitive effects, plus dependence risk. Used as reserve in cases refractory to first- and second-line agents. In resource-limited countries and the WHO Essential Medicines List, it retains a role as a basic antiepileptic.
- BTopiramateSecond line · Antiepileptic with multiple mechanismsSecond-line for focal and generalized epilepsy in adults and children over 2 per ILAE 2017. Starting dose 25 mg at bedtime with slow titration to 200–400 mg daily over 5–6 weeks. Less tolerable than lamotrigine and levetiracetam – more cognitive side effects (mental fogginess, word-finding problems).
How to read tiers A–F
Evidence tiers belong to the drug-indication pair, not to the drug as a whole: the same substance can be A for one condition and F for another.
- AStrong evidence – first or second line in international guidelines
- BRecommended in selected cases
- CStudy data contradict each other
- DBenefit not proven, no documented harm
- FDocumented harm, or risk without benefit