Two FDA-approved intranasal sprays — Nayzilam (midazolam) and Valtoco (diazepam) — are fundamentally changing how seizure clusters are managed outside of hospitals, giving caregivers a fast, dignified tool that replaces what was, for decades, a deeply impractical option. For families managing epilepsy alongside dementia or other neurological conditions, this shift matters enormously: a caregiver can now administer a single nasal spray during a seizure emergency without needles, without rectal gel, and without waiting for paramedics to arrive. In clinical trials, Nayzilam terminated seizures within 10 minutes in over 80 percent of patients, while Valtoco achieved a median time to seizure cessation of just 2 minutes when given promptly.
Before these medications reached the market — Nayzilam in May 2019 and Valtoco in January 2020 — the primary at-home rescue option was diazepam rectal gel, sold as Diastat. Anyone who has tried to administer a rectal medication to a confused, seizing adult in a living room or a public space understands why uptake was poor and why many caregivers simply called 911 instead. An estimated 150,000 or more people in the United States with uncontrolled epilepsy experience seizure clusters, and for those who also live with cognitive decline, the stakes of delayed treatment are even higher. This article walks through how these nasal sprays work, who they are approved for, what the clinical data actually shows, and what caregivers need to know about cost, limitations, and practical use.
Table of Contents
- What Are the Intranasal Drugs Changing Seizure Treatment at Home?
- How Effective Are These Nasal Sprays Based on Clinical Evidence?
- Long-Term Safety and What Caregivers Can Expect After Administration
- Nayzilam vs. Valtoco — Choosing the Right Rescue Spray
- Limitations and Situations Where Nasal Sprays May Not Work
- How Caregivers Should Prepare for a Seizure Emergency
- What the Future Holds for At-Home Seizure Treatment
- Conclusion
- Frequently Asked Questions
What Are the Intranasal Drugs Changing Seizure Treatment at Home?
The two medications currently approved are Nayzilam, a midazolam nasal spray manufactured by UCB, and Valtoco, a diazepam nasal spray from Neurelis. Both belong to the benzodiazepine class and work by calming excessive electrical activity in the brain during a seizure cluster — a pattern of repeated seizures that occur over a short period. What makes them different from older rescue treatments is the delivery method. A caregiver sprays a pre-measured dose into one nostril, and the drug is absorbed through the nasal mucosa into the bloodstream. No training in injection technique is needed. No undressing the patient is required.
Nayzilam is approved for patients 12 years of age and older. The standard dose is 5 mg delivered as one spray into one nostril, with the option to give a second spray 10 minutes later if the seizure continues. Valtoco was originally approved for patients 6 and older, but in April 2025, the FDA expanded its approval down to children ages 2 to 5. Valtoco uses a proprietary technology called INTRAVAIL, which enhances how diazepam is absorbed through the nasal lining — an important engineering detail, because diazepam is not naturally well-absorbed intranasally without help. For caregivers of older adults with dementia who also have epilepsy — a combination that is more common than many people realize — the simplicity of a nasal spray cannot be overstated. Administering rectal gel to someone who is confused, agitated, or physically resistant during a seizure was not just undignified; it was often dangerous for both patient and caregiver. These sprays remove that barrier entirely.
How Effective Are These Nasal Sprays Based on Clinical Evidence?
The clinical data behind both medications is solid, though not without caveats worth understanding. Nayzilam was evaluated in the ARTEMIS-1 Phase 3 trial, where 53.7 percent of patients receiving the drug met the primary efficacy endpoint, compared to 34.3 percent on placebo — a statistically significant difference (p=0.011). Looking more granularly, 80.6 percent of patients treated with Nayzilam had seizure termination within 10 minutes, versus 70.1 percent on placebo. Perhaps more meaningfully for daily life, 58.2 percent of Nayzilam patients experienced no seizure recurrence between 10 minutes and 6 hours, compared to 37.3 percent on placebo. Valtoco’s efficacy data tells a slightly different story because it was studied against its own predecessor — rectal diazepam gel — rather than placebo. The median time to seizure cessation with Valtoco was 2 minutes when administered within 5 minutes of seizure onset, and 87 percent of seizure episodes required only a single dose over a 24-hour period.
The FDA ultimately recognized Valtoco as clinically superior to the rectal gel formulation, granting it orphan drug exclusivity — a meaningful regulatory distinction that confirmed the nasal route was not merely more convenient but actually performed better. However, these numbers come with an important qualification. Efficacy depends heavily on timing. Both drugs work best when administered as early as possible after a seizure cluster begins. For caregivers of people with dementia, recognizing the onset of a seizure can be more complicated, particularly if the person already exhibits unusual movements or behaviors related to their cognitive condition. A seizure that is not identified for several minutes may not respond as quickly or completely, and caregivers should work with their neurologist to develop a clear seizure action plan that accounts for these recognition challenges.
Long-Term Safety and What Caregivers Can Expect After Administration
One concern that caregivers often raise is whether repeated use of these medications over months or years remains safe. Long-term data from Nayzilam studies is encouraging: across 769 seizure cluster episodes treated, 80.2 percent met the criteria for treatment success, with a 95 percent confidence interval of 77.2 to 83.0 percent. This consistency over hundreds of real-world uses suggests that the drug does not lose effectiveness with repeated administration — a worry that haunts many benzodiazepine therapies. After a dose of Nayzilam, the median time to return to baseline functionality is approximately 90 minutes, and 97.2 percent of patients who received a single dose returned to full baseline within 24 hours. This matters for planning.
If a person with dementia receives the spray during a seizure cluster at home, the caregiver should expect the individual to be drowsy and somewhat impaired for roughly an hour and a half. The most common side effects of Valtoco — somnolence, headache, and nasal discomfort at rates of 4 percent or higher — are mild and consistent with what you would expect from a nasal benzodiazepine. For the expanded pediatric population now covered by Valtoco’s April 2025 approval for ages 2 to 5, a Phase 1/2a study confirmed that the safety profile in young children was consistent with what had been seen in older patients. Adverse events were primarily mild nasal symptoms. While this article focuses on the dementia and brain health context, the pediatric expansion is worth noting because it reflects the FDA’s growing confidence in the intranasal delivery platform overall.
Nayzilam vs. Valtoco — Choosing the Right Rescue Spray
Caregivers and clinicians sometimes ask which of the two sprays is better, and the honest answer is that they serve slightly different needs. Nayzilam uses midazolam, a faster-acting benzodiazepine that is widely used in emergency rooms for acute seizure management. Valtoco uses diazepam, which has a longer duration of action and may offer a wider window of post-dose seizure protection. Neither has been tested head-to-head against the other in a randomized trial, so direct efficacy comparisons should be made cautiously. From a practical standpoint, there are differences worth weighing. Nayzilam is approved for ages 12 and up, while Valtoco now covers patients as young as 2.
For older adults with dementia, both are viable options, but the choice may come down to what other medications the person is taking, their individual response to midazolam versus diazepam, and insurance coverage. Cost is a real factor: Nayzilam runs approximately $40 per box of two doses commercially, with eligible patients potentially paying as little as $20 through co-pay assistance programs. Valtoco pricing varies, and caregivers should check with Neurelis directly about patient assistance options. One tradeoff to consider is the recovery timeline. Midazolam tends to cause more acute but shorter-duration sedation, while diazepam’s effects linger longer but may offer extended seizure suppression. For a caregiver managing someone with dementia, the choice might hinge on whether prolonged drowsiness is more or less disruptive than the risk of seizure recurrence in the hours following treatment.
Limitations and Situations Where Nasal Sprays May Not Work
These medications are not a replacement for daily seizure-prevention drugs, and it is critical that caregivers understand this distinction. Nayzilam and Valtoco are rescue medications — designed for acute seizure clusters, not for ongoing epilepsy management. A person with epilepsy and dementia still needs their baseline antiepileptic medication regimen, and a nasal spray should never be substituted for that. There are also situations where intranasal delivery may be less effective. If a person is seizing face-down, if their nose is congested due to a cold or allergies, or if there is significant nasal mucus or bleeding, absorption could be impaired.
Caregivers should have a conversation with their neurologist about backup plans for these scenarios — which might include calling emergency services or, in some cases, having an alternative non-nasal rescue medication available. People who are already on high doses of benzodiazepines daily may also experience a blunted response to these rescue sprays due to tolerance. Another limitation is awareness and access. Despite being approved since 2019 and 2020 respectively, many caregivers still do not know these nasal sprays exist. A 2023 survey by the Epilepsy Foundation found that awareness of rescue therapies among caregivers remained lower than clinicians expected. If you are caring for someone with both epilepsy and dementia, it is worth specifically asking their neurologist whether a nasal rescue spray should be part of the care plan — do not assume it will be offered automatically.
How Caregivers Should Prepare for a Seizure Emergency
Preparation is where these medications deliver their greatest value. A caregiver who has a Nayzilam or Valtoco device stored at room temperature, who knows where it is, and who has practiced the administration steps will be far more effective during the chaos of a real seizure than someone encountering the device for the first time under stress. Both products come with clear instructions and are designed for single-hand operation — you remove the cap, insert the nozzle into one nostril, and press the plunger.
For families managing dementia alongside seizure disorders, consider keeping the rescue spray in a consistent, accessible location — not locked in a medicine cabinet that requires a key during a crisis. Many neurologists now recommend doing a “dry run” with the packaging (not the actual medication) so that every caregiver in the household, including overnight aides or family members who visit regularly, knows the steps. Time matters: the clinical data consistently shows that earlier administration produces better outcomes.
What the Future Holds for At-Home Seizure Treatment
The success of Nayzilam and Valtoco has opened the door for further innovation in non-injectable, non-rectal seizure rescue. Researchers are investigating intranasal formulations of other antiepileptic compounds, and the INTRAVAIL technology used in Valtoco may be applied to drugs beyond diazepam.
The April 2025 expansion of Valtoco to younger children signals ongoing regulatory willingness to broaden access to these delivery systems. For the dementia care community specifically, the convergence of easier-to-use rescue medications with growing recognition that epilepsy is underdiagnosed in people with Alzheimer’s disease and other dementias could lead to meaningful improvements in quality of life. Seizures in dementia are often subtle — sometimes presenting as sudden confusion or staring spells rather than dramatic convulsions — and having a low-barrier rescue option may encourage more families and care facilities to screen for seizure activity and develop proactive treatment plans rather than relying solely on emergency department visits after the fact.
Conclusion
Intranasal seizure rescue sprays represent one of the most practical advances in epilepsy care in recent years, and their impact on home-based caregiving — particularly for people living with dementia — is difficult to overstate. Nayzilam and Valtoco have replaced an undignified, difficult-to-administer rectal gel with a simple nasal spray that non-medical caregivers can use confidently in any setting. The clinical evidence supports their effectiveness, with seizure termination rates exceeding 80 percent within 10 minutes for Nayzilam and a median cessation time of just 2 minutes for Valtoco.
If you are caring for someone who has both a seizure disorder and cognitive decline, talk to their neurologist about whether one of these rescue sprays belongs in your emergency toolkit. Ask about training, storage, and what to do if the spray does not work. These medications do not eliminate the need for emergency services in all situations, but they buy critical time and can prevent a seizure cluster from escalating into a hospital admission. In a caregiving landscape where so many challenges lack clean solutions, this is one area where the available tools have genuinely gotten better.
Frequently Asked Questions
Can a non-medical caregiver legally administer Nayzilam or Valtoco?
Yes. Both medications are specifically designed to be administered by non-medical caregivers, including family members, teachers, and coworkers. They are prescribed by a physician and dispensed with instructions for lay administration.
How should I store these nasal sprays?
Both Nayzilam and Valtoco should be stored at room temperature and kept in their original packaging until ready to use. Check the expiration date regularly and replace the device before it expires. Do not refrigerate.
What if the person’s nose is congested when they have a seizure?
Nasal congestion can potentially reduce absorption. If the person has significant nasal blockage, administer the spray as directed but be prepared to call emergency services if the seizure does not stop. Discuss backup rescue plans with the prescribing neurologist in advance.
Are these sprays safe to use alongside dementia medications like donepezil or memantine?
Benzodiazepines can interact with other central nervous system medications. Your neurologist should review the full medication list before prescribing a nasal rescue spray. In general, the short-term, intermittent use of these rescue medications is considered manageable, but sedation may be more pronounced in people already taking CNS-active drugs.
How quickly should I administer the spray once a seizure starts?
As soon as you recognize a seizure cluster is occurring. Clinical data for Valtoco showed a median seizure cessation time of 2 minutes when administered within 5 minutes of seizure onset. Faster administration correlates with better outcomes.
Is one spray enough, or will I always need a second dose?
In most cases, a single dose is sufficient. With Valtoco, 87 percent of seizure episodes required only one dose over 24 hours. With Nayzilam, a second spray may be administered 10 minutes after the first if needed, but the majority of patients respond to the initial dose.
