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''Aim ''
seizure free
no or acceptable SE

''Principles''
use one drug if possible (75% control with one drug)
second drugs may dec seizures and will increase SE (adding 2nd line dec fits by 50% in 30% people) needs neurologist
no one drug is better - need to try 
education / behaviour modification / family therapy - all help psychosocial functioning but don't dec seizures
CBT - helps depression but not seizures nor always psychosocial

start drug with pt agreement with neurologist at low dose and titrate up - usually after 2 seizures (after 1 refer to neurology - 2WW)
start 1st drug after 1 seizure IF neuro deficit, brain lesion, status, EEG shows generalized spike wave, pt/family request
consider stopping after >2y seizure free and tail off over 2-3/12

usually ...
partial seizures - ''Carbamazepine'' / Lamotrigine
generalized seizures - ''Valproate'' / Lamotrigine / Carbamazepine / (Levitiracetum)
Absence seizures (petit mal) - ''Valproate'' / Ethosuximide (Carbamazepine may exacerbate)
Myoclonic seizures - ''Valproate'' / Clonazepam / Lamotrigine

Stopping drugs - consider at 2 yrs no seizure with 2-3/12 tail

High rate psychosocial disfunctioning - low self esteem, anxiety, depression, social difficulty
Poor compliance - 1/3rd not seizure free as don't take Rx - poor understanding, lack of / misinterpretation of instructions
education - inc knowledge, adjustment, psychosocial function
Relaxation and behaviour modification also reduces anxiety and improves functioning
Family counselling - helps adjustment
CBT - decreases anxiety and depression
Of no benefit - yoga, biofeedback, relaxation alone

''Drugs''
common 
carbamazepine, phenytoin, lamotrigine, valproate (also clobazam and phenytoin - neither 1st line)
2nd line
Pregabalin, gabapentin, levetiracetum, topiramate, oxycabazepine, tigabine, vigabatrin, zonisamide, lacosamide

''Side effects''
All - sedation (sleepy/fatigue), headache, ataxia, dizziness, (SHAD) and maybe suicidal ideation
can cause paradoxical inc in seizure frequency and severity
idiosyncratic - agranulocytosis, Steven-johnson, aplastic anaemia, pancreatitis, serum sickness, allergic dermatitis, liver failure  (asap sal)
teratogenic - NTD, cleft lip/palate - 1.5% background, 2.5% carbamazepine, 5% lamotrigine, 7% valproate (worst around conception / early 1st T) also risks to fetus of seizure - needs to be maternal decision

eg
Valproate - weight gain, (nine) alopecia, tremor, - 9% stopped (WHAT)
Carbamazepine - rash, diplopia - 18% stopped
Vigabatrin - 40% get concentric visual field defects - can be irreversible

''Surgery ''
useful in drug resistant pts with complex partial seizures
decrease seizure rate and improves psychosocial
Vagus nerve stimulation - on L - electrode around nerve and battery pack on ant chest wall - regular pulses and additional manual ones (via magnet)
may cause hoarseness, cough, dyspnoea, pain, paraesthesia

When to refer
If suspect - refer to confirm diagnosis - 2WW 
If poor control - refer
If female of child bearing age - refer
ie mostly managed in secondary care
role for GPSI