The costs of epilepsy, one of the most common neurological diseases, affect society as a whole as well as patients themselves. Approximately 15% of patients with epilepsy are considered to have difficult-to-treat or treatment-refractory epilepsy, and their impact on healthcare systems is disproportionate to their number. It could be assumed that treating these patients would be cost effective, because of the significant disability that results from nontreatment.The cost of antiepileptic drugs can be a significant problem in itself, particularly since epilepsy is a chronic condition. In addition. Other direct (e.g. professional fees, investigation and hospitalisation expenses) and indirect (e.g. loss of productivity and impairment in quality of life) costs should not be overlooked when assessing the overall costs of the illness. Indirect costs are often significantly greater than direct costs.Recently, there has been increasing interest in the use of newer anticonvulsant drugs and surgery in the management of patients with apparently intractable epilepsy. Despite some general agreement about the indications for each of these therapies, systematic assessments of their relative cost effectiveness are still needed. Cost effectiveness in the use of newer, as well as older, therapies implies paying attention to the efficacy of the therapy, direct and indirect costs, patient quality of life (including cognition, behaviour, self-esteem, daily functioning and social activities), and the relationships that patients have with their families and society.Appropriate choice of therapy and judicious use of newer diagnostic procedures are important factors in planning the treatment of individual patients and developing treatment guidelines.