Epilepsy is managed through a combination of medication, lifestyle adjustments, and in some cases surgery or implanted devices. Anti-seizure medications control seizures in about 70% to 80% of people, making them the first and most common line of treatment. For the roughly 30% whose seizures don’t respond to medication, a range of other options can make a significant difference.
Anti-Seizure Medications
Medications are the starting point for nearly everyone diagnosed with epilepsy. These drugs work in two main ways: some calm overactive brain cells by blocking the electrical channels (sodium or calcium channels) that allow signals to fire too rapidly, while others boost the brain’s natural braking system, a chemical messenger called GABA that slows neural activity. A third group works through mechanisms that aren’t fully understood yet.
Drug-resistant epilepsy is defined as seizures that persist after trying at least two properly dosed medications. About 30% of people with epilepsy fall into this category, which is why medication alone isn’t the whole story. If your first two medications haven’t worked well, your neurologist will likely discuss the non-drug options below.
The Ketogenic Diet
A high-fat, very low-carbohydrate diet can substantially reduce seizures, especially in people whose medications aren’t enough. The classic ketogenic diet uses a 3:1 or 4:1 ratio of fat to combined carbohydrates and protein, pushing the body into a metabolic state called ketosis. This isn’t the same as casually “going keto” for weight loss. It requires medical supervision and careful meal planning.
A 2018 Cochrane review of 11 randomized trials found that up to 85% of children on the ketogenic diet experienced at least a 50% reduction in seizures, and 55% became seizure-free after three months. Results in adults with drug-resistant epilepsy are more modest but still meaningful: about 32% achieved at least a 50% drop in seizure frequency, with 9% seeing a reduction greater than 90%. The diet tends to work best when followed strictly, and many people find the restrictions challenging over the long term.
Surgery
For people with drug-resistant epilepsy whose seizures originate from a specific, identifiable area of the brain, surgery can be remarkably effective. One year after surgery, 77% of patients were seizure-free, compared to just 7% of those who continued with medication alone. That’s a striking gap, and it’s why epilepsy specialists often recommend surgical evaluation earlier rather than later for people who aren’t responding to drugs.
The most common procedure is temporal lobe resection, since the temporal lobe is where seizures most frequently start. Other options include removing tissue outside the temporal lobe, disconnecting the two halves of the brain (corpus callosotomy) to prevent seizures from spreading, or in severe cases, removing or disconnecting an entire hemisphere. The type of surgery depends entirely on where seizures begin and what brain tissue can safely be removed without affecting critical functions like language or movement.
Implanted Devices
Two main types of implanted devices help people whose seizures aren’t controlled by medication and who may not be candidates for traditional surgery.
Vagus nerve stimulation (VNS) involves a small device implanted under the skin of the chest, connected to the vagus nerve in the neck. It sends regular electrical pulses to the brain to reduce seizure activity. Results typically improve over time: by six months, roughly 45% to 65% of patients experience a 50% to 100% reduction in seizure frequency.
Responsive neurostimulation (RNS) takes a more targeted approach. Electrodes are placed directly at the seizure focus inside the brain and connected to a small stimulator embedded in the skull. The device continuously monitors brain wave patterns and, when it detects the electrical signature of an oncoming seizure, delivers brief pulses of stimulation to stop it before it spreads. This can happen thousands of times per day, and the system is personalized over time as physicians review the recorded brain data and fine-tune the detection settings.
Pharmaceutical CBD
A purified form of cannabidiol (CBD) is FDA-approved for seizures associated with three specific, severe forms of epilepsy: Lennox-Gastaut syndrome, Dravet syndrome, and tuberous sclerosis complex. This is not the same as over-the-counter CBD oil. The pharmaceutical version is a precisely dosed oral solution prescribed for patients one year of age and older.
In clinical trials, patients taking the medication saw a 39% to 43% reduction in seizure frequency, compared to 13% to 20% for placebo. These are meaningful improvements for conditions that are notoriously difficult to treat. The medication is typically added on top of existing anti-seizure drugs, not used as a replacement.
Sleep, Stress, and Other Triggers
Lifestyle factors play a larger role in seizure control than many people realize. Sleep deprivation is one of the most consistent seizure triggers across epilepsy types, reported as a precipitant in about 28% of people with generalized epilepsy and 27% of those with temporal lobe epilepsy. Alcohol, emotional stress, physical fatigue, and missed meals frequently co-occur with seizure episodes, and they often stack: a combination of poor sleep, stress, and alcohol is particularly risky.
Treating sleep disorders can improve seizure control even without changing medications. Several studies have shown that treating obstructive sleep apnea led to better seizure outcomes on its own. Prioritizing consistent sleep schedules, managing stress, limiting alcohol, and eating regular meals won’t replace medical treatment, but they form an important foundation that makes other treatments work better.
Rescue Medications for Seizure Emergencies
Some people with epilepsy experience seizure clusters, which are groups of seizures occurring close together. Fast-acting rescue medications can stop these episodes before they become dangerous. These are typically prescribed in advance so a caregiver or the person themselves can administer the medication outside of a hospital.
Options include nasal spray forms of midazolam (approved in 2019) and diazepam (approved in 2020), as well as rectal diazepam, which was the only FDA-approved home rescue option in the U.S. for many years. In Europe, a buccal (inside-the-cheek) midazolam solution is also available. Orally dissolving tablets that can be placed between the cheek and teeth offer another route that avoids the need for injections or rectal administration. Your neurologist can help determine which option makes sense based on the type and frequency of your seizure clusters.
What to Do During a Seizure
If you witness someone having a tonic-clonic seizure (the type involving stiffening and shaking), the CDC recommends these steps: ease the person to the ground, turn them gently onto their side with their mouth pointing downward to keep their airway clear, clear the area around them, and place something soft under their head. Remove their eyeglasses and loosen anything around their neck. Time the seizure, and call 911 if it lasts longer than five minutes.
Equally important is what not to do. Don’t hold the person down or try to restrain their movements. Don’t put anything in their mouth, which is a persistent myth that can cause real injury to their teeth or jaw. Don’t attempt mouth-to-mouth breathing during the seizure, as breathing typically resumes on its own afterward. Don’t offer food or water until the person is fully alert, as they could choke.