Second-Generation Anticonvulsants to Treat Epilepsy

Topiramate (e.g., Topamax®)—This drug is used with other anticonvulsant drugs in the treatment of partial seizures and generalized tonic-clonic seizures in adults and children aged 2 to 16. It also is approved to prevent migraine headaches. Its precise mechanism of action is unknown, but its anticonvulsant activity may be due in part to increasing GABA (gamma-aminobutyric acid), a neurotransmitter that inhibits excitation of nerve cells in the brain. It is available in oral form, including sprinkles for children, and is taken twice daily.

In March 2011, the U.S. Food and Drug Administration (FDA) released information indicating that topiramate increases the risk for birth defects such as cleft lip and cleft palate when taken during the first trimester of pregnancy. Prescribing information for this medication now includes a stronger warning about this risk but states that in some women with epilepsy, the potential benefits of the drug might outweigh the higher risk.

There are few drug interactions between topiramate and other medications or other anticonvulsants. Side effects include drowsiness, nausea, dizziness, coordination problems (e.g., loss of balance), impaired speech (e.g., aphasia), changes in taste, weight loss, and kidney stones. Children may have difficulty concentrating and may become aggressive. Acute glaucoma and visual abnormality, a potentially very serious complication, has been reported in a small number of patients. If abnormal visual symptoms occur, patients should notify a physician immediately.

In March 2014, the FDA approved Qudexy™ XR extended-release capsules to treat certain types of seizures (partial-onset seizures, primary generalized tonic-clonic seizures) in children 10 years of age and older and adults and in combination with other drugs to treat POS, primary generalized tonic-clonic seizures, or seizures associated with Lennox-Gastaut syndrome in people 2 years of age and older.

Qudexy is a broad-spectrum antiepileptic drug that is taken once a day. This drug, as well as the generic form (topiramate extended-release capsules) can be used as a monotherapy (single drug) or along with other medications and is available in strengths of 25 mg, 50 mg, 100 mg, 150 mg, and 200 mg. The capsules can be swallowed or carefully opened and sprinkled on food.

Common side effects include tingling sensations in the arms and legs, irregular eye movements, appetite loss, nausea, and others. Serious side effects, including vision loss, fever, increased blood acid level (metabolic acidosis), dizziness, and cognitive changes. Rarely—in about 1 out of 500 people who take the medication—it can cause suicidal thoughts or actions. Talk to your health care provider about other risks associated with Qudexy.

Gabapentin (Neurontin®)—This drug is indicated for the adjunct treatment of partial seizures, with or without secondary generalization. Although it is structurally related to the substance GABA (gamma-aminobutyric acid), it does not interact with GABA receptors in the brain, and its mechanism of action is unknown. It is available in oral form and is taken 3 times daily.

No laboratory monitoring of liver, kidney, or blood (hematologic) function is necessary. Side effects include fatigue, dizziness, and imbalance.

Lamotrigine (Lamictal®)—This drug is indicated for the adjunct treatment of partial seizures and for conversion to monotherapyin adults with partial seizures. Its precise mechanism of action is unknown. It is presently available in oral form and is taken twice daily. No laboratory monitoring of drug levels are necessary.

Side effects include headache, nausea, dizziness, and skin rash. The appearance of the potentially life-threatening skin rash, particularly for patients who also are taking valproate (Depakote®), should be reported immediately to a physician.

Lacosamide (Vimpat®)—This drug is approved as adjunctive therapy for partial onset seizures in people 17 years of age and older. It is available in oral tablets and in an injectable form, and is usually administered twice per day. Side effects of lacosamide include the following:

  • Dizziness (vertigo)
  • Double vision
  • Excessive sleepiness (somnolence)
  • Fatigue
  • Headache
  • Nausea and vomiting

Tiagabine (Gabitril®)—This drug is indicated for adjunct therapy in adults with partial seizures. Its mechanism of action may be related to its effect on the brain substance GABA (gamma-aminobutyric acid). It is available in oral form and should be given in divided doses 2 to 4 times daily.

No laboratory monitoring of tiagabine levels are necessary. Its metabolism may be altered when taken with other anticonvulsants. Side effects include dizziness and somnolence.

Levetiracetam (Keppra®)—This drug is approved for use in adults and children 4 years of age and older as adjunct therapy for the treatment of partial seizure disorders. It is available in tablet form and as an oral solution for patients who prefer a liquid or cannot swallow tablets, taken twice a day. Side effects can include fatigue, imbalance, and behavioral changes, which often dissipate after the first month of treatment.

Oxcarbazepine (Trileptal®)—This drug is indicated for monotherapy (used alone) and adjunct therapy (in addition to other medications) in adults who have partial seizures and as adjunct therapy in children aged 4 and older who have partial seizures.

Side effects are usually mild or moderate and include the following:

  • Abdominal pain, nausea, vomiting
  • Dizziness
  • Double vision
  • Drowsiness, fatigue
  • Hyponatremia
  • Loss of coordination, abnormal gait

Zonisamide (Zonegram®)—This drug is approved for use in adults as adjunct therapy for partial seizures. It has however, been used fairly extensively in other countries for use in other seizure types including generalized seizures, myoclonic seizures, and absence seizures. Zonisamide is taken twice a day. Side effects can include dizziness, imbalance, weight loss, and fatigue. Patients who are allergic to sulfonamide drugs should not use zonisamide because it is a derivative of this class of drug.

Pregabalin (Lyrica®)—This drug is approved for use in adults as adjunct therapy for partial onset seizures. Lyrica, which is also used to treat diabetic peripheral neuropathy and postherpetic neuralgia, can be taken 2 or 3 times a day.

Side effects include the following:

  • Blurred vision
  • Difficulty concentrating
  • Dizziness
  • Dry mouth
  • Peripheral edema (swelling)
  • Somnolence (excessive sleepiness)

Perampanel (Fycompa)—This medication was approved by the FDA in October 2012 to treat partial onset seizures in adults and children 12 years of age and older. Side effects include:

  • Blurred vision
  • Dizziness, balance problems, unsteadiness that can lead to falls
  • Drowsiness, excessive sleepiness
  • Fatigue
  • Infections
  • Irritability
  • Muscle weakness
  • Weight gain
  • Others

In November 2013, the FDA announced approval of eslicarbazepine acetate (Aptiom) as an add-on medication to improve seizure control for adults with partial seizures. Common side effects include the following:

  • Dizziness
  • Drowsiness
  • Double-vision
  • Fatigue
  • Headache
  • Loss of coordination
  • Nausea and vomiting

Updated by Remedy Health Media

Publication Review By: Gordon R. Kelley, M.D., Stanley J. Swierzewski, III, M.D.

Published: 01 Feb 2002

Last Modified: 14 Jul 2014