The commonest antiepileptics and their indications

1. Big picture

For the exam, antiepileptic drug choice is mainly based on seizure type / epilepsy syndrome, not simply on the EEG. The key practical rule is:

Focal epilepsy → carbamazepine / lamotrigine / levetiracetam-type drugs. Generalized epilepsy → valproate-type broad-spectrum drugs, but avoid valproate when pregnancy is possible if alternatives work. Absence epilepsy → ethosuximide if pure absence. Myoclonic epilepsy / juvenile myoclonic epilepsy → valproate is classically most effective; levetiracetam is an important alternative. West syndrome → ACTH/steroids and vigabatrin.

Modern guidelines increasingly prefer lamotrigine or levetiracetam as first-line focal-seizure monotherapy, with carbamazepine/oxcarbazepine as later options, mainly because of tolerability and interaction issues. But the classic exam answer still often associates carbamazepine with focal epilepsy. NICE also lists lamotrigine, levetiracetam and sodium valproate as first-line options for generalized tonic-clonic seizures, with important valproate restrictions.