NeuroPCP – Primary Care Neurology & Epilepsy CDS

Evidence Base

Designed for primary care clinicians managing first seizure, epilepsy, headache, TIA, and dizziness.

NICE NG217Epilepsies in children, young people and adults — updated January 2025

AAN/AES 2015First seizure guideline — reaffirmed October 2024

AAN 2018New-onset epilepsy update — efficacy & tolerability

AES 2024Status epilepticus algorithm — adults

This tool synthesizes guideline recommendations. Always apply clinical judgment and local pathways. Not a substitute for specialist advice.

Key 2025 updates integrated: MHRA/NICE strengthened valproate and topiramate restrictions for people under 55 with childbearing potential; lamotrigine remains preferred in pregnancy; CGRP pathway for migraine; immediate AED discussion after first unprovoked seizure per AAN/AES.

Primary Care Neurology Algorithms

Headache

Red flags: thunderclap, new onset >50y, cancer, immunosuppression, fever+neck stiffness, papilledema, progressive neuro deficit, pregnancy/post-partum severe, GCA features (jaw claudication, scalp tenderness).

Feature	Migraine	Tension-type	Cluster
Pain	Unilateral throbbing, mod-severe	Bilateral band-like pressure	Severe unilateral orbital
Duration	4–72h	30min–7d	15–180min
Associated	Nausea, photophobia, phonophobia	None	Ipsilateral lacrimation, rhinorrhea, ptosis, restlessness
Frequency	Variable	Frequent	Cluster bouts

Acute Triptan first-line; consider gepants (ubrogepant, rimegepant) if triptan contraindicated/fails.

Preventive CGRP mAbs (erenumab, galcanezumab, fremanezumab) for ≥4 migraine days/month after ≥2 oral preventives.

Same-day headache pathway reduces admissions by ~45%.

TIA / Stroke

FAST: Face droop, Arm weakness, Speech disturbance, Time to call emergency.

Immediate actions: If FAST positive & <4.5h — call 911/ED. If resolved TIA — do NOT delay.

Check glucose, vitals, neuro exam
ABCD2 calculator (see Calculators tab)
If no bleed suspected: give aspirin 300mg immediately
Refer <24h if ABCD2 ≥4, crescendo TIA, AF, or on anticoagulant
Refer <7 days if ABCD2 <4

Order same-day labs, ECG. Arrange carotid imaging per local stroke pathway.

Dizziness – Differentiate in Primary Care

	BPPV	Vestibular Neuritis	Posterior Circulation Stroke
Onset	Brief <1min with position	Acute persistent days	Sudden
Exam	Positive Dix-Hallpike, torsional nystagmus	Unidirectional nystagmus, +head impulse	Direction-changing nystagmus, skew, ataxia, dysarthria
Key test	Dix-Hallpike	HINTS (if trained)	HINTS + neuro signs
Action	Epley maneuver	Symptomatic, follow-up	ED immediate

Cannot exclude posterior stroke? → same-day ED. Do NOT use Dix-Hallpike if neck vascular disease.

First Seizure in Primary Care

1. Safety counseling — no driving, avoid heights/water alone, supervise bathing/cooking

2. History — witness account, video, provokers (sleep deprivation, alcohol, drugs), meds

3. Exam + core labs — neuro exam, glucose, Na, Ca, Mg, renal, LFT, FBC, ECG, pregnancy test

4. Urgent referral — first seizure clinic: EEG within 2 weeks, MRI brain within 4 weeks (urgent if focal deficit, red flags)

5. Document driving restrictions and provide written advice

Epilepsy Algorithm (Detailed)

First Unprovoked Seizure

AAN/AES 2015 (reaffirmed Oct 2024) recommends clinicians should inform adults that immediate AED reduces 2-year recurrence by ~35% compared with delayed treatment. Absolute benefit greatest in those with prior brain injury/insult or imaging abnormality (21–45% higher recurrence risk). Discuss risks/benefits and individualize decision.

When to start AED after 1st seizure: Patient preference after informed discussion AND high recurrence risk factors present.

When to Start Long-term AED

2 or more unprovoked seizures >24h apart
OR 1 unprovoked seizure with high recurrence risk: EEG epileptiform abnormality, MRI structural lesion, nocturnal seizure, Todd's paresis, remote symptomatic cause

Focal Onset

First-line: lamotrigine (Level B evidence ≥60y), levetiracetam, oxcarbazepine

AAN 2018 suggests lamotrigine, levetiracetam, zonisamide; also gabapentin, oxcarbazepine, topiramate may be considered over carbamazepine in some adults due to tolerability.

Generalized Tonic-Clonic

First-line: lamotrigine, levetiracetam

Valproate highly effective but Avoid <55y female

Absence / Myoclonic

Absence: ethosuximide, lamotrigine

Myoclonic: levetiracetam, valproate (avoid in women <55)

Avoid sodium-channel blockers (carbamazepine, oxcarbazepine, phenytoin) in generalized epilepsies — may worsen.

Special Populations (per guidelines)

Population	Preferred	Avoid / Caution
Elderly (≥60)	Lamotrigine or levetiracetam (Level B)	Avoid enzyme inducers, strong anticholinergics
Female reproductive age	Lamotrigine preferred	Valproate, topiramate per MHRA 2025 PPP required
Pregnancy / planning	Lamotrigine, levetiracetam (lowest risk)	Valproate contraindicated, topiramate avoid
Liver failure	Levetiracetam, lamotrigine (reduced), gabapentin	Valproate, phenytoin
Renal failure	Lamotrigine, valproate (dose adjust others)	Adjust levetiracetam, gabapentin, pregabalin
Depression / mood	Lamotrigine, oxcarbazepine (mood stabilizing)	Levetiracetam, topiramate, perampanel (irritability)

Valproate & Topiramate Restrictions – NICE 2025 / MHRA

Valproate: Contraindicated in pregnancy. For anyone under 55 with childbearing potential: only if no alternative AND enrolled in Pregnancy Prevention Programme with annual specialist review and signed risk acknowledgement.

Topiramate: 2025 update — avoid in pregnancy; effective contraception required for women of childbearing potential due to risks of congenital malformations and neurodevelopmental disorders. Counsel and document.

Status Epilepticus – AES 2024 Algorithm

0–5 min: ABCs, O₂, glucose, vitals. If no IV → IM midazolam 10mg (or buccal/intranasal)

5–20 min: IV access → lorazepam 4mg IV (repeat once) OR diazepam

20–40 min: Load second-line — levetiracetam 60mg/kg (max 4.5g) IV OR fosphenytoin 20mg PE/kg OR valproate 40mg/kg (avoid if pregnant/liver)

>40 min refractory: ICU, intubation, continuous infusion (midazolam, propofol, ketamine). Treat cause.

Medication Reference Table

Drug	Seizure Types	Starting Dose	Target Dose	Key Monitoring	Pregnancy	Notes
Lamotrigine	Focal, GTC, absence	25mg daily ×2wk (with valproate 12.5mg alternate days)	100–200mg BID	Rash (SJS risk), mood	Preferred	Slow titration essential; avoid rapid escalation. Level B ≥60y.
Levetiracetam	Focal, GTC, myoclonic	500mg BID	1000–1500mg BID	Mood/behavior, renal	Low risk	No interactions; adjust in renal failure.
Oxcarbazepine	Focal	300mg BID	600–1200mg BID	Na+ (hyponatremia)	Moderate risk	Mild enzyme inducer; check Na+ at baseline & 2–4wk.
Carbamazepine	Focal	200mg BID	400–600mg BID	CBC, LFT, Na+, HLA-B*1502	Teratogenic	Avoid in absence/myoclonic; strong inducer. Hyponatremia risk.
Valproate MHRA 2025	GTC, focal, myoclonic, absence	250mg BID	500–1000mg BID (level 50–100)	LFTs, platelets, pregnancy test	CONTRAINDICATED	Only specialist use <55y with PPP, annual RISK form. Highest teratogenicity.
Topiramate MHRA 2025	Focal, GTC	25mg nightly	100–200mg BID	Bicarbonate, cognition, weight	Avoid	Cognitive slowing, kidney stones, weight loss. Contraception required <55y.
Gabapentin	Focal	300mg qhs	300–600mg TID	Renal	Limited data	Sedation, edema; no drug interactions.
Lacosamide	Focal	50mg BID	100–200mg BID	PR interval	Unknown	IV available; reduce if PR prolongation or severe renal.
Zonisamide	Focal, GTC	100mg daily	200–400mg daily	Bicarbonate, renal stones	Avoid	Weight loss, sulfa allergy caution.
Ethosuximide	Absence only	250mg BID	500mg BID	CBC	Limited	First-line childhood absence; ineffective for GTC.
Clobazam	Adjunct focal, LGS	5mg qhs	10–20mg BID	Sedation, tolerance	Risk	Short-term rescue use; taper to stop.
Brivaracetam	Focal	50mg BID	50–100mg BID	Mood	Limited	Analog of levetiracetam; fewer behavioral effects in some.
Cenobamate	Focal refractory	12.5mg daily	200mg daily	QT shortening, DRESS	Unknown	Very slow titration q2wks; drug interactions.
Perampanel	Focal, GTC	2mg qhs	4–8mg qhs	Mood/aggression	Unknown	Bedtime dosing; enzyme inducer reduces levels.
Phenytoin	Focal, GTC	100mg TID	300–400mg daily (level 10–20)	Level, CBC, LFT, gums	Teratogenic	Non-linear kinetics; many interactions; avoid in new onset.
Phenobarbital	Focal, GTC	30–60mg qhs	90–180mg daily	Sedation, cognition	Risk	Strong inducer; cognitive side effects limit use.

Warnings: Lamotrigine rash — slow titration, stop if rash+fever. Oxcarbazepine/carbamazepine — check sodium. Valproate — MHRA 2025 Pregnancy Prevention Programme mandatory.

Safety Counseling

Driving Laws (US Typical)

Most states require 3–6 months seizure-free (varies by state)
Must report to DMV in some states (CA, DE, NV, NJ, OR, PA)
First unprovoked seizure: advise no driving until neurology clearance
Document counseling in note
Commercial drivers: stricter FMCSA rules

SUDEP Discussion

Suggested script: “SUDEP is when a person with epilepsy dies suddenly without clear cause. Risk is about 1 in 1000 per year, lower if seizures controlled. Biggest risk is frequent tonic-clonic seizures, especially at night.”

Modifiable factors: take AEDs regularly, avoid sleep deprivation & excess alcohol, consider nocturnal supervision/alarms, aim for seizure freedom.

Rescue Medication

Buccal midazolam 10mg adult (0.2mg/kg child) for seizure >5 min
Intranasal midazolam or diazepam rectal gel alternatives
Repeat once after 5 min if still seizing
Call 911 if: >5 min, repeated without recovery, injury, breathing difficulty
Train family; check expiry every 6 months

Contraception & Pregnancy Planning

Enzyme inducers ↓ OCP efficacy: carbamazepine, phenytoin, phenobarbital, oxcarbazepine, topiramate >200mg, perampanel, cenobamate — recommend IUD/implant
Lamotrigine levels ↓ with OCP — may need dose increase
Valproate/topiramate: highly effective contraception mandatory for women <55y per NICE 2025
Preconception: start folic acid 4–5mg, refer to epilepsy specialist

References

NICE NG217. Epilepsies in children, young people and adults. Updated January 2025.
Krumholz A et al. AAN/AES Guideline: Management of an unprovoked first seizure in adults. Neurology 2015;84:1705–1713. Reaffirmed October 2024.
Kanner AM et al. AAN Practice Guideline Update: Efficacy and tolerability of new antiepileptic drugs I & II. Neurology 2018;91:74–103.
American Epilepsy Society. Algorithm for Convulsive Status Epilepticus in Adults — 2024 Update.
MHRA. Valproate and topiramate: strengthened safety measures, 2025.
Johnston SC et al. ABCD2 score validation. Lancet 2007;369:283–292.
Stewart WF et al. MIDAS disability assessment. Neurology 2001;56(6 Suppl 1).

All dosing is adult unless specified. Verify with local formulary and BNF/SmPC.

NeuroPCP — Primary Care Neurology & Epilepsy