Up to 70% of people who are treated with a single anticonvulsant will enter remission within a short time of being diagnosed with epilepsy.1 Optimal first choice treatments have been identified in some comparative randomised controlled trials and guidelines from the National Institute for Health and Clinical Excellence.2 3 Lamotrigine or carbamazepine are usually the preferred initial treatment of seizures with localised onset in the brain, whereas valproate is preferred for generalised epilepsy syndromes.4 5

However, despite optimal doses of a first line anticonvulsant, many patients with localised onset seizures (10-15/100 000 each year worldwide) do not enter remission and continue to have seizures of varying severity and frequency, which are associated with considerable psychosocial distress.6 7 The evidence base to support management of these patients is minimal,2 and it is uncertain which of the following available options is optimal:

• Continue with the existing first line treatment as monotherapy.

• Switch to …