Optimal medical management of epilepsy requires consideration of many factors. As a first step, the decision to start antiepileptic drug treatment should be based on a thorough diagnostic evaluation and careful assessment of the risk–benefit ratio for the patient. Although achieving seizure control is a most important objective, seizures are not the only cause for concern in people with epilepsy. Any associated neurological, psychological, psychiatric and social handicaps need to be addressed. Optimal management should also include a discussion of factors that could impact negatively on seizure control (e.g. poor adherence to the prescribed treatment schedule, or sleep deprivation), without placing undue restrictions on the patient's lifestyle. Counselling about marriage, reproduction, driving regulations and other legal matters may be indicated.

If treatment is indicated, the choice of the antiepileptic drug should be tailored to the characteristics of the patient, including seizure type, epilepsy syndrome, age, gender, comorbidities and any concurrently taken medications. Drug treatment is generally started at a low dose and up-titrated gradually, aiming at identifying the lowest maintenance dosage that controls seizures without causing undue adverse effects. Clinical response should be regularly monitored, and special attention should be given to identification and management of potential side-effects.

If the initially prescribed drug used at optimized dosage fails to control the seizures completely, diagnostic re-evaluation may be warranted. Monotherapy with an alternative antiepileptic drug may then be tried, although some patients may benefit from early introduction of combination therapy. When combination therapy is used, consideration should be given to the possibility of adverse pharmacokinetic and pharmacodynamic drug interactions, which may require adjustments in dosage. Not all drug combinations are equally effective, and evidence has accumulated that some antiepileptic drug combinations can be more efficacious and better tolerated than others. Particularly in patients with difficult-to-control epilepsy, caution must be taken to avoid overtreatment (i.e. the situation where the side-effects of medication adversely affect quality of life more than the seizures themselves).

The duration of antiepileptic drug therapy also needs to be individualized, and the feasibility of gradually discontinuing medications may be considered after at least 2 years of seizure freedom. The decision whether to withdraw or continue treatment requires careful discussion with the patient and/or the parents, and should take into consideration not only the risk (and consequences) of seizure recurrence, which is largely dependent on the patient's epilepsy syndrome, but also the risks of adverse effects resulting from continuation of therapy.