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associated with weight gain, endocrine problems and fertility problems. Lamotrigine and
levetiracetam are being used increasingly as a first-line drugs. They have a wide spectrum of
action and are well tolerated. They are not associated with the weight gain and endocrine
problems reported with sodium valproate. However, oestrogen decreases lamotrigine blood
levels and this interaction may cause problems with oral contraceptives and during
pregnancy. For those adolescents with seizures of partial onset who either cannot tolerate the
adverse effects of AEDs or refuse to take them, self-control of seizures can be offered. This
method may be effective in suppressing at least a proportion of partial seizures, especially
those which are heralded by a clear aura.

In treatment-resistant seizures the possibility of non-epileptic attacks must always be
considered and should be managed appropriately with a positive, non-punitive attitude. The
concept of ‘locus of control’ is important. An approach which is often helpful is to say:
‘Wouldn’t it be wonderful if you were in control of the attacks instead of the attacks being in
control of you?’ The adolescent should be encouraged to find a way of controlling the attacks.
He or she should be reviewed after a specified period of time, for example three weeks. If
there is any reduction in the frequency of the attacks he/she should be praised for having done
so well and for having begun to gain control themselves. Sometimes a change of life situation
may be necessary.

The possibility of seizures precipitated by substance abuse must also be considered, although
screening of patients in accident and emergency departments has shown that this is a
relatively uncommon cause of presentation with seizures. A number of substances may be
associated with the precipitation of seizures in people who do not necessarily have epilepsy.
If substances such as alcohol or benzodiazepines are used in large intermittent doses
(‘bingeing’), then withdrawal effects may precipitate seizures. Seizures as a result of cocaine
toxicity have been reported in a number of publications9. Ecstasy may also precipitate
seizures. If substance abuse is suspected then a urine specimen should be sent for toxicology
testing. Hair testing may also be useful in this context. Testing of hair is not of value in the
acute situation but can be helpful in determining whether substances have been abused in the
recent past and may offer some temporal indication of when the substance misuse took place.
Treatment of the underlying substance abuse, rather than the prescription of an AED, is
appropriate in these cases.

If the cause of the seizures is neuronal antibodies, for example anti-NMDA receptor
antibodies or voltage-gated potassium channel complex antibodies, prompt treatment with
immunotherapy can be curative and can also treat, prevent or minimise additional
complications.

Surgery may be indicated in a number of circumstances. The most obvious of these is a
tumour presenting de novo in adolescence. Some teenagers may have had a history of
complex partial seizures for many years and MRI scanning may reveal mesial temporal
sclerosis, a dysembryoplastic neuroepithelioma or a hamartoma. It could be argued that these
patients should have had surgery earlier. If surgery is necessary, it is probably better to carry
this out sooner rather than later. The longer the seizure disorder affects education,
development and the social situation, the more difficult it will be to overcome the adverse
effects of the epilepsy, even if the seizures themselves are controlled.

Conclusions

Adolescence is an exciting but uncertain period. If epilepsy presents for the first time in
adolescence, this adds greatly to complexities of this period. Well-established epilepsy may
vary over the course of adolescence, increasing the uncertainty when so many other changes