What nonpharmacologic therapy may be considered for refractory seizures?

• A. Ketogenic diet, vagus nerve stimulation, and, in select cases, surgical resection or responsive neurostimulation.
• B. Only daily exercise.
• C. Vitamin supplements alone.
• D. Herbal teas.

Answer: (A)

When seizures remain uncontrolled despite trying multiple antiepileptic drugs, nonpharmacologic therapies become an important consideration. The combination of ketogenic diet, vagus nerve stimulation, and, in select cases, surgical resection or responsive neurostimulation represents a range of approaches that address seizure control through metabolism, neuromodulation, and targeted removal or interruption of epileptic activity.

The ketogenic diet alters brain energy use by promoting ketosis, which can reduce neuronal excitability and seizure frequency in some patients, particularly in pediatric cases but also used in adults. Vagus nerve stimulation provides regular electrical pulses to the vagus nerve to modulate brain networks and lower seizure burden when a clear surgical target isn’t suitable. Responsive neurostimulation detects early abnormal activity and delivers timely stimulation to prevent seizures, offering another option for focal epilepsy when resection isn’t feasible or has not fully controlled seizures. Surgical resection removes the epileptogenic brain tissue when a well-defined focus is present and resection is unlikely to cause unacceptable deficits.

Other non-specific approaches like daily exercise, vitamin supplements, or herbal teas lack consistent evidence for controlling refractory seizures on their own, though they may support overall health.