The epilepsies are one of the most common serious brain disorders, can occur at all ages, and have many possible
presentations and causes. Although incidence in childhood has fallen over the past three decades in developed
countries, this reduction is matched by an increase in elderly people. Monogenic Mendelian epilepsies are rare. A
clinical syndrome often has multiple possible genetic causes, and conversely, diff erent mutations in one gene can
lead to various epileptic syndromes. Most common epilepsies, however, are probably complex traits with
environmental eff ects acting on inherited susceptibility, mediated by common variation in particular genes.
Diagnosis of epilepsy remains clinical, and neurophysiological investigations assist with diagnosis of the syndrome.
Brain imaging is making great progress in identifying the structural and functional causes and consequences of the
epilepsies. Current antiepileptic drugs suppress seizures without infl uencing the underlying tendency to generate
seizures, and are eff ective in 60–70% of individuals. Pharmacogenetic studies hold the promise of being able to
better individualise treatment for each patient, with maximum possibility of benefi t and minimum risk of adverse
eff ects. For people with refractory focal epilepsy, neurosurgical resection off ers the possibility of a life-changing
cure. Potential new treatments include precise prediction of seizures and focal therapy with drug delivery, neural
stimulation, and biological grafts.
Epilepsy is a disorder of the brain characterised by an
enduring predisposition to generate epileptic seizures,
and epileptogenesis is the development of a neuronal
network in which spontaneous seizures occur. Epilepsy
aff ects the whole age range from neonates to elderly
people, and has varied causes and manifestations, with
many distinct seizure types, several identifi able
syndromes, but also much that is poorly classifi ed. There
are very many comorbidities that complicate assessment
and treatment planning, including learning disabilities,
fi xed neurological defi cits, progressive conditions,
psycholo gical and psychiatric problems, and, particularly
in the older age group, concomitant medical conditions.
Classifi cation of epileptic seizures and syndromes is
continually evolving. The present proposed classifi cation
is across fi ve axes that consider seizure types, focal or
generalised seizure onset, the syndrome, causation, and
associated defi cits.1 Here, we have defi ned individuals
aged 16 years and older as adults. The UK National
Institute for Health and Clinical Excellence (NICE)
produced in October 2004 detailed evidence-based
guidelines2 for the clinical management of individuals
with epilepsy (panel). Other guidelines include those of
the American Academy of Neurology and the Scottish
Intercollegiate Guidelines Network.
Stigma and prejudice mark epilepsy out from other
neurological conditions. The past decade has seen
considerable progress in epilepsy research, and
improvement in public understanding. Much, however,
remains to be done, especially for people for whom drugs
are ineff ective. An important issue that needs urgent
attention is the fact that most people with epilepsy live in
resource-poor countries where the management of
epilepsy is inconsistent. There is a great diagnostic gap in
large parts of the world because there are too few trained
personnel and medical facilities. The WHO-led Global
Campaign Against Epilepsy with the active support of the
International League Against Epilepsy and International
Bureau for Epilepsy (the two major international
non-governmental organisations in epilepsy) is seeking
to address these issues.3,4 Additionally, there is a large
treatment gap in resource-poor countries, and worldwide,
less than 20% of people with the disorder are estimated to
be treated at any time.5,6 However, resolving these
diffi culties will require tremendous eff ort and will take
time to achieve. Most of what we discuss here relates to
diagnosis and treatment of epilepsy as seen in the
developed world. We hope that before long, the same
standards will be achieved in resource-poor countries.