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Epilepsy FAQs
Answers to Your Questions on Epilepsy Management

Released: August 25, 2023

Pavel Klein
Pavel Klein, MD, FAAN, FAES
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Key Takeaways
  • Rescue therapies for epilepsy should not be used chronically.
  • The prophylactic use of rescue therapies for epilepsy is done off label.
  • In the event of a seizure/seizure cluster, administering rescue therapy quickly is key.

How would you instruct a patient to use their seizure rescue therapy as a prophylactic agent in the following scenarios?

  1. A known trigger to the patient’s seizures is extreme stress; she currently is planning her wedding, and it is causing extreme stress, but the wedding is 1 month out
  2. A known trigger to the patient’s seizures is sleep deprivation; he stayed awake until 5:00 AM to complete a work project on time

In setting A, because this is a chronic stress that lasts for days on end, it is not feasible to have the patient take the rescue therapy as a prophylactic. This is because rescue therapies are not meant to be used more than 5 times a month and should not be used repetitively within 3-5 days of previous rescue therapy use (depending on formulation). I would instruct this patient to use the rescue medication only in the event of a seizure.

In setting B, I would instruct the patient to use the rescue medication prophylactically the day following his sleep deprivation because that is when a seizure would be expected to occur for him. However, it is important to note that prophylactic use of rescue medications is off label.

When using seizure rescue therapies as prophylactic agents, how long does the prophylactic effect last?

The expected duration of the prophylactic effect is likely up to 1 day. It may be less with midazolam than with diazepam because of the difference in their half-lives. Generally speaking, the evaluated periods range from 6-24 hours.

If someone does have a seizure event/cluster that requires rescue medication, after taking the rescue medication to stop the seizure in the moment, should they be instructed to take a second dose later in the day to prevent another seizure event from occurring?

I would instruct them to take a second dose if they experience another seizure that day, but I would not suggest using rescue therapy as a prophylactic agent following a seizure evert that was successfully stopped by 1 dose. The boundary for repeat dosing is difficult to draw, especially in scenarios where the seizure threshold has been reduced. However, because the prophylactic use of rescue medications is off label, it should be done carefully. Otherwise, it becomes easy to end up in a situation where the limitation of the medication indication is reached (ie, do not use more than 5 times per month). It also opens up more potential for abuse of or dependency on the rescue medication. For example, if someone has anxiety and epilepsy, they may feel stressed all the time and use the medication frequently to quell their anxiety about experiencing a seizure—before you know it, they become dependent on the rescue medication for anxiety control.

How would you manage epilepsy in a patient with comorbid anxiety without putting too much emphasis on a benzodiazepine?

It is okay for a patient who uses benzodiazepines indicated for anxiety management to also be prescribed a rescue medication for seizures, but the comorbid anxiety should not be managed with the rescue medication. If possible, the patient should be using a nonbenzodiazepine agent to manage anxiety. You may wish to consult with a psychiatry provider for this.

What do you take into consideration when choosing between an intranasal diazepam or intranasal midazolam rescue therapy formulation for patients? Would you prescribe a patient both a midazolam and a diazepam formulation of rescue medication so they can determine which one works best for them?

For me, choosing between these formulations is based on 2 variables: (1) the known (if it is known) pattern of seizure clustering for the individual and (2) the pharmacokinetic profile of the medications. Although both are efficacious, intranasal midazolam has a shorter half-life and time to peak plasma concentration—and, therefore, a shorter time to peak brain concentration—than intranasal diazepam. Thus, I likely would prescribe the midazolam formulation to a patient who is likely to have another seizure within the next hour and the diazepam formulation to a patient who is likely to have another seizure within the next 6-8 hours. Of course, regardless of this, each patient’s individual seizure pattern, comorbidities, and situation should be considered when deciding between these formulations.

Regarding the second part of this question, I would not prescribe both formulations at the same time. Instead, I would prescribe one based on clinical judgment, as mentioned above; if that formulation fails, I would then prescribe the alternate formulation for the patient to try.

What are your strategies for educating patients and their caregivers/family members on how to use an intranasal rescue medication?

We have a demonstration intranasal device in the office that I use when teaching patients. The demonstration is very straightforward and takes approximately 1 minute, so I do it as a standard. I also ask if they have any questions, and I will let them try the demonstration device if they want to do so.

Information on using their intranasal rescue medication, including when and how, should also be included in the seizure action plan so that patients and caregivers/family can revisit the instructions outside of an appointment.

What advice do you have for administering rescue medication safely during a seizure?

This will differ based on the type of seizure and the type of rescue medication formulation. For example, you would not want to use a buccal film formulation (ie, clobazam [off label]) for a bilateral tonic-clonic seizure because you might get your hand bitten. A buccal film formulation might be appropriate for a focal seizure or an escalation of myoclonic jerks or absence seizures. However, because you do not know if these seizures will turn into a bilateral tonic-clonic seizure, you would need to administer a buccal film formulation quickly to avoid any injuries should a tonic-clonic seizure begin while you are administering it.

When administering an intranasal formulation, you also want to be as quick as possible to get the plunger into the patient’s nostril and press it to release the medication. You would not want to restrain the person in any way when administering the medication, as some patients may fight back when restrained mid seizure, and this could cause injury to themselves or others.

Your Thoughts?

Do you use rescue therapies for your patients with epilepsy? Answer the polling question and join the conversation by leaving a comment. For more education on developing seizure action plans and using rescue therapies for seizure clusters, watch the on-demand webcast, “Time Is Brain: Seizure Action Plan to the Rescue.”

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