Which AED is useful only for generalized seizures, especially absence seizures in 

childhood absence epilepsy?

Adrenocorticotropic hormone (ACTH) initially;

valproic acid for maintenance therapy 

Benign Rolandic Epilepsy

(Benign Childhood Epilepsy with Centrotemporal Spikes)

Ethosuximide

(Can also use valproic acid)

Valproic Acid is preferred is generalized Tonic-Clonic seizures are also present

• School-Aged Onset
• EEG: Generalized 3 Hz spike and wave
• Good response to VPA, ESM, LTG, TPM, ZNS
• May (usually) remit spontaneously

• Idiopathic
• Genetic and Metabolic
• Focal Brain Malformations

Infantile Spasms

(West Syndrome if includes Dev. Delay)

• Onset in first 2 years (usu. 3-9 months)
• EEG: Hypsarrhythmia
• Developmental plateau or regression
• MR is part of def. of West Syndrome, but not all infants with infantile spasms and hypsarrhythmia have intellectual impairment
• Tx: ACTH, VGB, VPA, Prednisone

• Onset Common in Adolescents (12-18 years)
• Myoclonic and generalized TC sz ON AWAKENING
• 10% of all epilepsies
• Tx: Valproic Acid (Lamotrigine and Topiramate are newer alternatives)
• Excellent Prognosis but Discontinuation of AEDs is NOT RECOMMENDED

Initial AED choices for Focal Onset Sz

(Partial, Secondary Generalized)

CBZ, OXC

(LTG, LEV)

Initial AED choices for Generalized Onset Sz

Tonic-Clonic, Myoclonic, Atonic/Tonic

VPA, LTG, TPM

(ZNS, FBM)

Initial AED choices for Generalized Onset Sz

Absence

Initial AED choices for Generalized Onset Sz

Infantile Spasms

ACTH, VGB

(TPM, ZNS)

• Infantile Spasms (Hypasrrhythmia)
• Mental Retardation
• May be flexor (salaam, jackknife or head nodding), extensor, or mixed (Most Common)
• Spasms usu. occur when awake, upon awakening, or in drowsiness period before sleep
• Tx: ACTH or Prednisone

West Syndrome

(Etiology)

• Perinatal (hypoxia-ischemia, infection, prematurity or hemorrhage)
• Genetic (Tuberous Sclerosis or Aicardi Syndrome)
• Malformations of cortical development
• Inborn errors (e.g.- PKU)
• Idiopathic (40% of cases)

• Generalized Epilepsy (multiple types, including atonic or myoclonic attacks
• Onset in childhood
• MR
• EEG: Generalized slow spike and slow wave complexes and background slowing
• Seizures often intractable; may require several antiepileptic meds
• Ketogenic diet or vagusnerve stimulation may be helpful
• Tx: Valproic Acid (VPA)

• Onset: School-age or teenage years
• Typically Complex Partial with automatisms
• EEG: Temporal Lobe Sharp Waves
• May be intractable
• Rate of spontaneous remission is low
• MRI critical to rule out structural lesion/mass
• Carbamazepine is first-line Tx
• Refractory cases may be candidates for epilepsy surgery

Initial AED choices for

Lennox-Gastaut Syndrome

Clonazepam

Valproate (VPA)

Initial AED choices for

Juvenile Myoclonic Epilepsy

Initial AED choices for

Benign Focal Epilepsy of Childhood

Carbamazepine (CBZ)

Gabapentin (GBP)

Carbamazepine

(CBZ)

Ethosuximide

(ESM)

• Initial Tx of absence seizures
• VPA more appropriate is GTC sz also present
• Advantages:
• Few serious side effects (rare bone marrow suppression)
• Long half-life
• Drawbacks:
• GI Upset
• Possibility of some cognitive effects

Felbamate

(FBM)

• Broad-spectrum activity against partial sz, 2^o generalized TC sz, and the multiple generalized sz types of Lennox-Gastaut
• Strikingly free of adverse effects on cognition or alertness
• RISK OF FATAL APLASTIC ANEMIA OR HEPATOTOXICITY
• CBC and LFT every 2 weeks
• Decreases clearance of PHT, VPA, CBZ epoxide (metabolically-active metabolite of CBZ)
• FBM clearance increased by CBZ and PHT
• FBM clearance decreased by VPA

Gabapentin

(GBP, Neurontin)

• Partial and secondarily generalized TC seizures
• Low toxicity; minimal cognitive impairment
• No drug-drug interactions (not plasma bound; excreted unmetabolized by the kidneys)
• Adverse Effects:
• Transient dizziness
• Lethargy
• Ataxia
• Weight gain
• Paradoxical aggression

Lamotrigine

(LTG, Lamictal)

• Effective against partial or secondarily generalized TC seizures, absence seizures, and generalized seizure-types, including Lennox-Gastaut
• Low toxicity profile; minimal cognitive impairment
• Adverse effects
• Lethargy, Ataxia, HA
• SEVERE skin rash (SJS) in as many as 1/100 (esp if on VPA or LTG introduced quickly)