When drugs don't work: An algorithmic approach to medically intractable epilepsy

Nonpharmacologic options for the treatment of epilepsy include epilepsy surgery, vagus nerve stimulation, and the ketogenic diet. The advantages and limitations of these treatment modalities have been extensively reviewed, but there is no general consensus on when each option should be considered. The authors propose an algorithm based on the type of epilepsy. Generally, nonpharmacologic options should be considered early - i.e., after the first few drug failures. Because of their good outcome with resective surgery, mesial temporal and lesional neocortical epilepsies should be considered for resection. Conversely, nonlesional neocortical epilepsies are probably best approached with vagus nerve stimulation first. For symptomatic or cryptogenic generalized epilepsies, which are commonly intractable, vagus nerve stimulation and the ketogenic diet appear to be reasonable options to consider before palliative surgery such as corpus callosotomy. Idiopathic (i.e., genetic) generalized epilepsies are only rarely refractory to medications and can be outgrown. In rare cases, vagus nerve stimulation may occasionally play a role in their treatment.