Study flags stark inequities in global epilepsy care, medication

A new global analysis conducted by researchers at Aston University paints a mixed picture of epilepsy care in low- and middle-income countries.

Titled "Antiseizure medications consumption in 73 countries and regions from 2012 to 2022: A longitudinal trend study", the analysis found that although access to antiseizure medications has grown substantially, patient safety has not advanced at the same pace.

Its review of treatment patterns across 73 countries found that valproate, an effective but high-risk drug, remains the most widely used option, despite well-documented dangers during pregnancy, including birth defects such as spina bifida and cleft palate, along with long-term neurodevelopmental challenges affecting cognition, communication, behaviour, and memory.

Epilepsy is a brain condition that causes repeated seizures. A seizure happens when the brain’s electrical activity becomes abnormal for a short time. This can make a person shake uncontrollably, lose consciousness for a few seconds or minutes, or experience unusual sensations, such as tingling or 'strange smells'. Epilepsy can begin at any age. Some people develop it due to brain injury, infections, or genetic factors, but in many cases, the exact cause is unknown.

Antiseizure medications, also called antiepileptic drugs, help prevent or reduce seizures. They do not cure epilepsy, but they help control it. Older medicines include valproate, phenytoin, and carbamazepine, while newer medicines include levetiracetam and lamotrigine.

Greater availability of established drugs has helped narrow the global treatment gap, but progress is overshadowed by persistent shortcomings in prescribing practices, particularly in regions with limited training or outdated clinical practices. As a result, expanded access has not always translated into safer or more effective care for people with epilepsy.

One of the most striking findings is the continued widespread use of valproate, a medication strongly associated with birth defects and neurodevelopmental disorders when taken during pregnancy. Even with clear safety warnings and regulatory restrictions, valproate remains a popular choice in many countries. Its low cost, broad availability, and clinician familiarity often outweigh safety concerns, especially where safer alternatives are scarce or prohibitively expensive.

The World Health Organisation (WHO) considers valproate high-risk for women and girls of childbearing potential.

It has issued formal guidance advising that valproate should generally be avoided in this group because of the strong evidence linking it to serious birth defects and developmental disorders in children exposed during pregnancy.

These risks include neural tube defects such as spina bifida, cleft palate, and other structural abnormalities, as well as long-term neurodevelopmental problems affecting learning, memory, communication, and behaviour.

When treating epilepsy or related conditions in women of reproductive age, WHO recommends prioritising safer alternatives such as lamotrigine or levetiracetam whenever possible. If a woman is already taking valproate, she should receive thorough counselling about the potential risks to a future child and use effective contraception throughout treatment.

If pregnancy is planned or occurs, consultation with a specialist experienced in managing epilepsy or bipolar disorder during pregnancy is strongly advised, and switching to safer medications before conception should be considered.

WHO has also added a cautionary note regarding valproate on its list of essential medicines, emphasising that its use in women of childbearing age should only occur when necessary. In cases where valproate is the only viable treatment option, careful monitoring, specialist oversight, and informed decision-making are crucial to minimise potential harm.

The study also reveals significant barriers to accessing newer antiseizure medications such as levetiracetam and lamotrigine, which pose lower risks for women of reproductive age. In many low- and middle-income countries, these drugs are unavailable, unaffordable, or inconsistently supplied. Even when they are present, financial and logistical obstacles limit their use. This forces clinicians to rely heavily on older drugs that carry greater safety risks.

Consumption data between 2012 and 2022 illustrate these trends. Global antiseizure medication use rose from roughly 40.96 to 52.87 defined daily doses per 10,000 inhabitants per day, indicating that many more people, including those previously untreated, gained access to care. The growth was driven mostly by newer-generation drugs; levetiracetam consumption increased by an average of 21.72 per cent per year, and lamotrigine by 7.48 per cent per year.

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Meanwhile, use of older medications such as phenytoin, phenobarbital, and carbamazepine declined. This shift suggests that, where resources allow, treatment is becoming more aligned with modern clinical standards.

However, the progress is highly uneven. In 2022, high-income countries consumed more than four times as many antiseizure medications as lower-middle-income countries. The disparity highlights how limited access to medication, particularly newer and safer ones, continues to undermine equity in epilepsy care.

Perhaps the most concerning finding is the persistence of valproate as the most commonly used antiseizure medication globally in 2022, including in many low- and middle-income countries where its use has even increased.

Despite decades of safety warnings, valproate remains entrenched, likely due to cost, availability, and its reputation as a broad-spectrum drug. This continued reliance on a high-risk medication underscores serious public-health concerns, especially for women and girls who may become pregnant.

The global rise in antiseizure medication use signals real progress: broader access, improved treatment coverage, and, in some settings, a shift toward more modern therapies. Yet the unevenness of this progress raises significant safety and equity issues.

Many countries still lag far behind, both in the volume of medications consumed and in access to safer options, while reliance on older, riskier drugs persists.

The researchers call for coordinated global action, stronger provider education, tighter regulatory safeguards, and improved access to safer medications to ensure that increased availability leads to meaningful improvements in patient outcomes.