Antiepileptic drugs (AEDs) are a treatment modality for the suppression of seizures. Medical therapy is usually the first option once it is established that seizures should be prevented. This is a worthwhile goal not only with a confirmed diagnosis of epilepsy but also when there is a clear indication to prevent further (acute symptomatic) seizures. Several possible indications for initiating AEDs will be discussed in this chapter.

The decision to start long-term AED treatment should never be undertaken by the treating physician alone as it requires exhaustive information and discussion with the parents, and—if the age and intelligence are appropriate—with the child. This discussion should consider the expected efficacy as well as the tolerability of treatment. The balance between possible benefit and risks will ultimately determine whether the child will be treated.

In established epilepsy, the benefit of the first AED will be seizure-freedom in about 50%, while the risks of (serious) adverse events or side effects is approximately 15%. The frequency and severity of the seizures as well as the prognosis of the particular epilepsy type should be taken into account. Therefore, the approach to AED therapy must be individualized as the patient’s individual reaction to an AED is difficult to predict, both as regards seizure reduction as well as side effects. In this chapter, we will consider the possible indications to start an AED for the prevention of seizures.

The clearest indication for initiating AED maintenance therapy is the proven recurrence of epileptic seizures. The diagnosis of epilepsy should be firmly established through clinical signs while the characteristic EEG features help confirm the type of epilepsy.

However, there are other situations where AEDs are advocated when the diagnosis of epilepsy is questionable or where seizures have been provoked acutely. Figures 46–1, 46–2, 46–3, 46–4 review the various situations that invite consideration of the use of AED therapy to prevent (further) seizures. Each is briefly discussed.

STARTING AEDS FOR CONFIRMED SEIZURES OR EPILEPSY

The current belief is that AEDs suppress seizures, but do not heal the epilepsy. Gower’s paradigm (“Seizures beget seizures”) was formerly popular, and AEDs were thought to prevent intractable epilepsy.^1,2 It is now understood that medical intractability is not based on the number or severity of seizures but on the nature of the underlying neurological disorder.³ Others⁴ could not confirm that a decreasing interval between seizures facilitates further seizures.

From a clinical standpoint, the course of the epilepsy is favorable if it remits spontaneously and unfavorable if severe underlying disease or conventional medical suppression of seizures are insufficient to prevent intractability.^3,5 In the latter situation, epilepsy can be considered a “progressive” disorder. However, this situation is highly variable as the course of epilepsy may change during long-term follow-up.⁶