NICE guidance - use of newer drugs for epilepsy in children

Summary points from the updated NICE Guidance are presented below. The guideline covers diagnosing and managing epilepsy in children, young people and adults in primary and secondary care, and referral to tertiary services. It aims to improve diagnosis and treatment for different seizure types and epilepsy syndromes, and reduce the risks for people with epilepsy. (1)

MHRA advice on antiepileptic drugs in pregnancy: Recommendations on carbamazepine, gabapentin, lamotrigine, levetiracetam, oxcarbazepine, phenobarbital, phenytoin, pregabalin and zonisamide have taken into account the MHRA updated safety advice on antiepileptic drugs in pregnancy.

MHRA advice on valproate: Recommendations on valproate have been updated following publication of the MHRA guidance on the use of valproate, valproate use in people younger than 55 years, valproate use in women and girls and valproate use in men.

Valproate must not be started for the first time in people (male or female) younger than 55 years, unless 2 specialists independently consider and document that there is no other effective or tolerated treatment, or there are compelling reasons that the reproductive risks do not apply.

Valproate must not be used in women and girls of childbearing potential (including young girls who are likely to need treatment into their childbearing years), unless other options are unsuitable and the Pregnancy Prevention Programme is in place.

Boys and men should be advised to use effective contraception (condoms, plus contraception used by a female sexual partner) throughout the valproate treatment period and for 3 months after stopping valproate. Men taking valproate who are planning a family within the next year should discuss potential fertility risks and treatment options with a healthcare professional.

MHRA advice on topiramate: Recommendations on topiramate have taken into account the MHRA guidance on the use of topiramate Topiramate should not be used in women of childbearing potential unless the conditions of the Pregnancy Prevention Programme are fulfilled.

For generalised tonic-clonic seizures:

Offer a choice of lamotrigine, levetiracetam or sodium valproate as first-line monotherapy for generalised tonic-clonic seizures. If monotherapy is unsuccessful in people with generalised tonic-clonic seizures, consider 1 of the following first-line add-on treatment options:

• clobazam
• lamotrigine
• levetiracetam
• perampanel
• sodium valproate (follow the MHRA safety measures and precautionary advice for sodium valproate)
• topiramate (do not use topiramate in women and girls of childbearing potential unless the conditions of the Pregnancy Prevention Programme are fulfilled).

If first-line add-on treatments tried are unsuccessful in people with generalised tonic-clonic seizures, consider 1 of the following second-line add-on treatment options:

• brivaracetam
• lacosamide
• phenobarbital
• primidone
• zonisamide.

Note - be aware that the following antiseizure medications may exacerbate seizures in people with absence or myoclonic seizures, including in juvenile myoclonic epilepsy:

• carbamazepine
• gabapentin
• lamotrigine (for myoclonic seizures)
• oxcarbazepine
• phenytoin
• pregabalin
• tiagabine
• vigabatrin

Treatment should be reviewed at regular intervals to ensure that children with epilepsy are not maintained for long periods on treatment that is ineffective or poorly tolerated and that concordance with prescribed medication is maintained.

The recommendations on choice of treatment and the importance of regular monitoring of effectiveness and tolerability are the same for specific groups, such as children with learning disabilities, as for the general population of children with epilepsy.

For more details consult the full guidance.

Reference:

1. NICE. Epilepsies in children, young people and adults. NICE guideline NG217. Published April 2022, last updated August 2026