If Anti-Seizure Meds Don’t Work for Epilepsy, Can Surgery Help?
Epilepsy is one of the most common neurological disorders, affecting 3.4 million Americans or 1 in 26 over a lifetime. The hallmark of epilepsy is seizures caused by abnormal bursts of electrical energy in the brain that can lead to convulsions and loss of consciousness followed by disorientation. Everyday activities like cooking and driving can be dangerous.
Although there are about 30 epilepsy medications, one-third of patients do not become seizure-free.
Vikram Rao, MD, PhD, is the division chief of the UCSF Comprehensive Epilepsy Center and a leading researcher on implanted devices. He explains how these treatments may have life-changing effects. And he reveals ongoing research that may offer relief to many more patients.
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Vikram Rao, MD, PhD,
Division Chief, UCSF Comprehensive Epilepsy Center
Why don’t medications work for some patients?
Just 1 in 5 patients who do not become seizure-free with medications find their way to a comprehensive epilepsy center, which offer the broadest range of diagnostic evaluations and advanced treatments.
The biggest reason medications don’t work is because the patient may not have epilepsy. Determining this may require patients to undergo seizure monitoring by specialists like those at UCSF Comprehensive Epilepsy Center. Among this group, the most common misdiagnosis is psychogenic non-epileptic spells (PNES), which is seen in about 25% of patients at specialized epilepsy centers. It may mimic epilepsy, but it’s psychological in origin and is usually seen in people with a history of trauma. These patients shouldn’t be treated with anti-seizure medications.
Also, some people with epilepsy cannot tolerate anti-seizure medications at the doses needed to control seizures. And sometimes medications are ineffective for reasons we don’t understand.
If medication doesn’t work, what other options are available?
If you ask patients what’s the worst thing about epilepsy, they often say the side effects of medications. Anti-seizure medications work by dampening electrical activity in the brain. But they don’t discriminate very well between seizure activity and normal “housekeeping” brain activity that helps us think and feel and remember. So, many medications cause dizziness, fatigue, incoordination, and brain fog. While some types of epilepsy go into remission, most patients require lifelong treatment.
Another treatment option is surgery. This involves removing the brain tissue that is causing seizures. But even with the most successful surgery, stopping medicines too quickly doesn’t usually go well. If patients are seizure-free one year after surgery, we’ll talk about slowly tapering, but some people still need medications for the long haul.
So, why do the surgery if it means the patient must continue taking medicine?
What we find is that the chance of becoming seizure-free after trying a handful of medications plummets to less than 1%. Whereas with surgery, there can be up to an 80% chance of becoming seizure-free. That’s a huge difference.
What are the surgical options for patients with drug-resistant epilepsy?
For the 60% of patients with focal seizures, those occurring in a specific area of the brain, several surgical procedures can help reduce seizures. Often, seizure-producing brain tissue can be safely removed through an open surgery. For seizures in deep, hard-to-access areas, we use laser thermal ablation. The surgeon makes a small incision in the scalp, and a tiny hole is drilled into the skull, enabling a heated laser, guided by MRI, to destroy abnormal tissue.
Are there implantable devices?
Yes, there are implantable devices connected to electrodes that deliver electrical pulses to the brain. These include responsive neurostimulation (RNS), which detects seizures as they begin and nips them in the bud; and deep brain stimulation (DBS), which provides intermittent stimulation to reduce abnormal brain activity.
A third, older technique, vagus nerve stimulation (VNS), entails a battery implanted in the chest that sends signals to stop seizures to the brain, via the vagus nerve in the neck. VNS does not require brain surgery, and it is the only device approved for children.
An RNS neurostimulator that attaches to lead wires which enable the sensing of brain activity and delivery of electrical pulses to seizure-producing brain tissue. Photo by Susan Merrell
What research is underway to push treatments forward?
One clinical trial using RNS has shown clinically meaningful results in preliminary data, for patients with generalized seizures affecting both sides of the brain simultaneously. A second trial focuses on pediatrics and adults with Lennox-Gastaut syndrome (LGS), a rare, severe epilepsy that often begins in childhood.
Another exciting development is a trial at UCSF for patients using RNS that looks at brain activity over long periods to forecast seizures within the next 24 hours. We have built a smartphone app that provides an estimate of the chance of seizures that day, like a weather forecasting app that tells you the chance of rain. We can’t give blanket guarantees, but we know from patient surveys that most appreciate advance notice of what the day may hold.
Have you seen profound changes in patients who become seizure-free?
Seizure freedom opens a world of possibilities. Some patients drive again, get a job, and enjoy meaningful relationships that might not have been possible if they were having several seizures a month and were reluctant to leave home. Some patients with long-term seizures develop cognitive decline, and surgery can plateau or even reverse these changes.
Surgery doesn’t work for everyone. My goal is to be conservative in counseling patients. I don’t want to raise unrealistic expectations, but it’s essential to maintain hope. It’s wonderful to have so many treatment options for epilepsy, unlike many other areas of neurology. There’s always something else to try, so we never give up.
Source: https://www.ucsf.edu/news/2025/09/430761/if-anti-seizure-meds-dont-work-epilepsy-can-surgery-help