Treatment of focal status epilepticus is similar to therapy for convulsive status epilepticus, although in some cases simply instituting oral antiseizure drug therapy is sufficient. Focal status epilepticus must be distinguished from absence status epilepticus, which is a prolonged, generalized absence seizure that usually lasts for hours or even days. Absence status epilepticus can often be effectively treated with a benzodiazepine followed by intravenous valproate or oral or nasogastric ethosuximide. Absence status epilepticus can occur when an inappropriate antiseizure drug, such as tiagabine or carbamazepine, is used in a patient with idiopathic generalized epilepsy.
Acute repetitive seizures, also referred to as seizure clusters, are groups of seizures that occur more frequently than the patient’s habitual frequency. The clusters can occur rapidly over several minutes, or they may occur over a longer time period of 1 or 2 days. In acute repetitive seizures, there is complete recovery between seizures so that patients do not meet the definition of status epilepticus. However, the condition is concerning nevertheless because, in the absence of treatment, prolonged seizures or status epilepticus can occur. Acute repetitive seizures can be treated in the emergency department with intravenous benzodiazepines or other antiseizure drugs. In the USA, diazepam rectal gel is the only approved treatment for out-of-hospital treatment of acute repetitive seizures. Outside the USA, rectal paraldehyde is sometimes used. Administering rectal medications can be difficult, time consuming, and an embarrassing experience for the patient and caregivers; such products are generally limited to use in children because of the social stigma and the mechanical difficulties of positioning adults. Buccal (oromucosal) midazolam, in which the treatment solution is administered to the buccal mucosa using an oral syringe, is commonly used in Europe and elsewhere in the world. Intranasal midazolam, diazepam, and lorazepam have also been shown to be efficacious; these drugs are not approved for this route of administration in the USA, but some clinicians use intranasal midazolam or oral benzodiazepines on an off-label basis.
Most women with epilepsy who become pregnant require continued antiseizure drug therapy for seizure control. No antiseizure drug is known to be completely safe for the developing fetus.