American Epilepsy Society

Five Things Physicians and Patients Should Question

Released August 15, 2018

  1. 1

    Avoid routine testing for antiepileptic drug (AED) levels in people with epilepsy.

    AED level testing should not be routinely ordered when seizures are well controlled, and no adverse effect is suspected. The reference ranges should not be used as a rigid framework. The effectiveness and tolerability of treatments should be determined by the clinical responses. AED levels should be ordered to address a specific question. Some examples include weight-based dosing adjustments in young children, adherence, suspected toxicity, and pregnant women.

  2. 2

    Do not treat females of childbearing potential with Valproate if other effective treatments are available.

    The risks to an unborn child from valproate (VPA) are significant enough to warrant avoiding this medication if at all possible. If VPA is deemed necessary, aim for lowest effective dose. Females on VPA should receive risk counseling prior to conception including possibility of major malformations from first trimester exposure, and long-term cognitive and behavioral effects (lower IQ and increased risk of autism spectrum disorder and ADHD) throughout pregnancy.

  3. 3

    Do not routinely order electroencephalogram (EEG) as part of initial syncope work-up.

    EEG will be negative in a large portion of patients with epilepsy, and may be positive in patients without epilepsy. False positive EEG findings commonly lead to unnecessary use of antiepileptic drugs and may delay the syncope diagnosis and treatment. EEGs are most helpful in specific situations when there is high pre-test probability for epilepsy based on history and exam, and clinical presentation.

  4. 4

    Do not prescribe long-term treatment with antiepileptic drugs after withdrawal seizures.

    Alcohol and other withdrawal seizures occur due to abrupt cessation in a person who is substance-dependent, and can usually be readily identified by the clinical scenario. Once the acute detoxification is complete, anti-epileptic drugs are not indicated. It is, however, important to identify scenarios where there is increased risk of epilepsy, such as prior epilepsy diagnosis, acute intoxication related brain injury, and seizures with history of alcohol use but without acute withdrawal.

  5. 5

    Do not routinely perform brain imaging after acute seizure in patients with established epilepsy.

    Unnecessary brain imaging increases radiation exposure and medical cost without benefit, yet is often done after habitual seizures when the patient is at baseline. Brain imaging should be considered in certain clinical situations, such as when there is seizure-related trauma or post-ictal deficits on exam.

These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.

The American Epilepsy Society mission centers on sharing knowledge, fostering continuous learning, discovering and applying innovations, acting through partnerships, and supporting current and future generations of those focused on achieving our vision of eradicating epilepsy and its consequences. Education, research, clinical excellence, public education, and awareness—these initiatives all align in the service of this vision.

How This List Was Created

The American Epilepsy Society (AES) and the AES Practice Management Committee (PMC) worked together to prepare the five statements from 2016–2018. The PMC met in person in December 2016 to use the ABIM Foundation’s Operating Principles for Clinician Organizations’ Participation in the Choosing Wisely Campaign to discuss and propose topics for further development. The PMC ultimately proposed seven potential topics for further discussion and tasked a subgroup of seven committee members to draft seven Choosing Wisely statements. Once drafted, each item was voted upon by the PMC subgroup for further inclusion.

Voters were provided additional instructions to select the item for further inclusion if it had (1) clinical relevance, (2) clinical validity, and (3) clarity of concept. Voting occurred electronically. Two items were eliminated, and five items were selected for further and final development. The final five items were completed by individual PMC subgroup members. The entire PMC subgroup then reviewed each statement for final editing and final vote for submission to Choosing Wisely, based on the same criteria mentioned above. Items receiving at least six “yes” votes (among seven voters) were advanced and reformatted and edited by the Practice Committee Chair, Dr. Gabriel Martz, to adhere to the ABIM Foundation’s Choosing Wisely submission specifications. The PMC subgroup then re-evaluated items to ensure consistency of message after re-formatting, and again voted on each item individually for or against advancement for review and consideration of approval by the AES Council on Clinical Activities, AES Executive Committee, AES Board of Directors. The AES Board of Directors provided feedback and final approval of the five statements for submission to the ABIM Foundation for consideration of inclusion in the Choosing Wisely Campaign. The PMC will review the statements on an annual basis to ensure adherence to the Foundation’s Operating Principles and that the statements continue to be supported by generally accepted evidence and are applicable to current clinical practice.


  1. Eadie MJ Therapeutic drug monitoring – antiepileptic drugs. Br J Clin Pharmacol 1998; 46:185-193.

    Patsalos PN et al Antiepileptic drugs—best practice guidelines for therapeutic drug monitoring: A position paper by the subcommission on therapeutic drug monitoring, ILAE Commission on Therapeutic Strategies. Epilepsia 2008, 49(7):1239–1276.

    St. Louis EK Monitoring Antiepileptic Drugs: A Level-Headed Approach. Current Neuropharmacology, 2009, 7:115-119.

    Affolter N et al Appropriateness of serum level determinations of antiepileptic drugs. Swiss Med Wkly 2003; 133:591-597.

    Tomson T et al Therapeutic monitoring of antiepileptic drugs for epilepsy (Review). Cochrane Database of Systematic Reviews 2007, Issue 2. Art. No.: CD002216. Copyright © 2010 The Cochrane Collaboration. John Wiley & Sons, Ltd.

    Walters RJL et al Inappropriate requests for serum anti-epileptic drug levels in hospital practice. Q J Med 2004, 97:337-341.

    Stepanova D, Beran RG. The benefits of antiepileptic drug (AED) blood level monitoring to complement clinical management of people with epilepsy. Epilepsy Behav. 2015; 42:7-9.

  2. Campbell E1, Kennedy F2, Russell A3, Smithson WH4, Parsons L5, Morrison PJ6, Liggan B7, Irwin B1, Delanty N8, Hunt SJ1, Craig J1, Morrow J1. Malformation risks of antiepileptic drug monotherapies in pregnancy: updated results from the UK and Ireland Epilepsy and Pregnancy Registers. J Neurol Neurosurg Psychiatry. 2014 Sep;85(9):1029-34. doi: 10.1136/jnnp-2013-306318. Epub 2014 Jan 20.

    Hernández-Díaz S1, Smith CR, Shen A, Mittendorf R, Hauser WA, Yerby M, Holmes LB; North American AED Pregnancy Registry; North American AED Pregnancy Registry.

    Comparative safety of antiepileptic drugs during pregnancy. Neurology. 2012 May 22;78(21):1692-9. doi: 10.1212/WNL.0b013e3182574f39. Epub 2012 May 2.

    Tomson T1, Battino D, Bonizzoni E, Craig J, Lindhout D, Sabers A, Perucca E, Vajda F; EURAP study group. Dose-dependent risk of malformations with antiepileptic drugs: an analysis of data from the EURAP epilepsy and pregnancy registry. Lancet Neurol. 2011 Jul;10(7):609-17. doi: 10.1016/S1474-4422(11)70107-7. Epub 2011 Jun 5.

    Tomson T1, Marson A2,3, Boon P4, Canevini MP5, Covanis A6, Gaily E7, Kälviäinen R8,9, Trinka E10,11,12. Valproate in the treatment of epilepsy in girls and women of childbearing potential. Epilepsia. 2015 Jul;56(7):1006-19. doi: 10.1111/epi.13021. Epub 2015 May 16.


    Angus-Leppan. Diagnosing epilepsy in neurology clinics: a prospective study. Seizure 2008; 17 (5): 431-6.

    Josephson CB, Rahey S, Sadler RM. Neurocardiogenic Syncope: Frequency and consequences of its misdiagnosis as epilepsy. Canadian Journal of Neurological
    Sciences. 2007; 34 (2): 221-224.

    Chowdhury FA, Nashef L, Elwes RDC. Misdiagnosis in epilepsy: A review and recognition of diagnostic uncertainty. Eur J Neurol 2008; 15(10): 1034-1042.

    Fowle AJ, Binnie CD. Uses and abuses of the EEG in epilepsy. Epilepsia 2000; 41 Suppl 3: 10-18.

    Van Donselaar CA, Stroink H, Arts WF; Dutch Study Group of Epilepsy in Childhood. How confident are we of the diagnosis of epilepsy? Epilepsia. 2006; 47 Suppl 1:9-13.

  4. Rogawski, MA. “Update on the Neurobiology of Alcohol Withdrawal Seizures”. Epilepsy Curr. 2005 Nov; 5(6):225–230. doi:10.1111/j.1535-7511.2005.00071.x

    Leach, J. P., Mohanraj, R. and Borland, W. “Alcohol and drugs in epilepsy: Pathophysiology, presentation, possibilities, and prevention” Epilepsia (2012), 53: 48–57. doi:10.1111/j.1528-1167.2012.03613.x

    Rogawski, MA. “Update on the Neurobiology of Alcohol Withdrawal Seizures”. Epilepsy Curr. (2005) Nov; 5(6):225–230. doi:10.1111/j.1535-7511.2005.00071.x

  5. Stiell IG, Clement CM, Rowe BH, Schull MJ, Brison R, Cass D, Eisenhauer MA, McKnight RD, Bandiera G, Holroyd B, Lee JS, Dreyer J, Worthington JR, Reardon M, Greenberg G, Lesiuk H, MacPhail I, Wells GA. Comparison of the Canadian CT Head Rule and the New Orleans Criteria in patients with minor head injury. JAMA. 2005 Sep 28;294 (12):1511-8.

    Kavalci C, Aksel G, Salt O, Yilmaz MS, Demir A, Kavalci G, Akbuga Ozel B, Altinbilek E, Durdu T, Yel C, Durukan P, Isik B Comparison of the Canadian CT head rule and the new orleans criteria in patients with minor head injury. World J Emerg Surg. 2014.

    Harden CL, Huff JS, Schwartz TH, Dubinsky RM, Zimmerman RD, Weinstein S, Foltin JC, Theodore WH; Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Reassessment: neuroimaging in the emergency patient presenting with seizure (an evidence-based review): report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology. 2007 Oct 30;69(18):1772-80.

    American College of Emergency Physicians, Best Practices for Seizure Management in the Emergency Department.