I am 26 with focal epilepsy for 3 years. Why no relief yet?

Question

Hi doctor,

I am 26 and was diagnosed with focal epilepsy three years ago, but I am still having breakthrough seizures despite medication. My EEG shows epileptiform activity in the left temporal region, and my MRI revealed mild hippocampal sclerosis. I am currently on Levetiracetam 1000 mg twice daily and Lamotrigine 200 mg twice daily, but I still have around three complex partial seizures monthly.

My recent blood levels showed Levetiracetam at 18 μg/mL (therapeutic range 12 to 46) and Lamotrigine at 8.5 μg/mL (target 3 to 14). The seizures usually involve staring, lip smacking, and confusion lasting around two minutes, followed by postictal confusion for 15 to 20 minutes.

Last month, I had a tonic-clonic seizure at work and was taken to the ER. It was humiliating. My driver's license was suspended, and I lost my job because I could not drive to work reliably. The antiepileptic drugs are affecting my memory and concentration.

I feel mentally sluggish all the time. Should we increase dosages or add a third medication like Topiramate? What about epilepsy surgery evaluation?

I am scared of brain surgery, but these seizures are destroying my independence and future prospects. Are there newer medications or treatment approaches I should know about?

Please advise.

Answer 1

Hi,

Welcome to icliniq.com

I understand your concern.

You have been doing your best for years, and I understand how frustrating and isolating it can feel, especially when your independence, work, and confidence are all being affected by seizures and the medications. The combination you are on, Levetiracetam and Lamotrigine, is often effective, and your drug levels are within range, so it is clear you are taking them correctly.

But since you are still having multiple seizures each month (and now a generalized one), your condition likely meets criteria for drug-resistant epilepsy. That means we need to seriously look beyond just adjusting doses.

Yes, adding a third medication like Topiramate, Lacosamide, or newer agents like Cenobamate or Perampanel is an option. However, more medications do not always mean better control, especially if memory and cognition are already being affected.

Sometimes a third drug just adds side effects without fully stopping the seizures. Given your MRI shows left hippocampal sclerosis and the electroencephalogram (EEG) confirms seizure activity from that area, you might be a candidate for epilepsy surgery, especially temporal lobectomy, which has a high success rate in carefully selected patients.

I know the idea of brain surgery is scary, but in experienced centers, this is a well-studied and often life-changing procedure. You would first need a full pre-surgical workup: video EEG monitoring, neuropsychological testing, and high-res imaging.

Another less invasive option could be responsive neurostimulation (RNS), a small device implanted in the brain that detects and responds to seizure activity in real time. It is considered when surgery is not possible or if there are concerns about memory loss after resection. You deserve a fresh, expert look at your case.

I would strongly recommend referral to an epilepsy center for evaluation, not just medication adjustment. There are options to help you regain control and independence. You have lived with this long enough.

I hope this answers your questions.

Thank you.