It is primordial to have a precise diagnosis for the type of
SEIZURES and the type of EPILEPSY.
There is usually no urgency to start an AED. It is preferable to
take the time for a good history, a good physical and a good set of
investigations including EEG, preferably with sleep EEG.
For example it is easy to diagnose a West syndrome, but it is much
better to distinguish a cryptogenic one from a symptomatic one. Treatment and
prognosis may well be different.
Similarly, a child may well present with what appears to be absences. But if the EEG does not show any generalized, regular 3 c/s SW, it may be complex partial seizures which will respond better to Tegretol.
We will always look for the best adapted AED, with the least side effects. Monotherapy will be efficacious in 50% of cases, a change in AED will bring this control rate to 66 %. In the remaining 25% a polytherapy will have to be initiated. 75% of patients are controlled with one or 2 AED's, multiple AED's therapy brings this number up to about 80%. In 20% of cases, the seizures are refractory to treatment. In these children the Ketogenic diet has brought lots of help.
3. When to treat?
The choice is either:
-Treat the aetiology
-Treat the seizures.
One has to weight the benefice vs the side effects: long term treatment,
label of chronic disorder, side effects of AED.
In children one also needs to take into account 1: the pharmacocinetic
(absorption, distribution, elimination) 2: the taste of the medication 3: the
presentation. eg: think twice before prescribing VPA to an obese child.
Must be clinical, biological controls, pharmacological control,and
5. When to stop?
2 to 3 years seizure-free. Relapse rate depends on type of
epilepsy, type of seizures, age of onset, duration of seizures, EEG.
6. What medication?
There are several medications that can be used. Traditionally the choice of anticonvulsant was as follows:
Tonic-clonic: V P A, C B Z, P H T
Absences: V P A, E S M
Infantile Spasms: C Z P
Myoclonic: V P A, C Z P
Simple Partial Seizures: C B Z, P H T, V P A
Complex Partial Seizures: C B Z, P H T, V P A
Secondary Generalized: C B Z, P H T, V P A
VPA: Valproic Acid
More recently it has appeared that most of the AED's have the same efficacy as first intention (in the appropriate cases of course).