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Discussing the usefulness of drugs in childhood epilepsy, Dr Newton (January 2004, JRSM1) suggests that ‘After two seizures most people will have a further seizure and this is probably the pivotal point at which the decision to treat or to delay treatment should be made’. Since antiepileptic drugs do not alter the natural course or long-term remission rate of epilepsy, the primary aim of treatment is to prevent seizure recurrence. In certain patients the recurrence rate after a single episode is particularly high—for example, those with a history of brain injury;2 those who had status epilepticus;3 and those who had a partial rather than a generalized seizure.4 The risk of recurrence after a first episode of seizure is much higher in children with abnormal electroencephalograms (EEGs) than in those with normal EEGs (80% versus 31%).5 Those with an abnormal CT scan at initial seizure have a higher risk of recurrence than those with normal scans.6 Though I agree with Dr Newton that antiepileptic drugs (AEDs) are generally not required after a first episode of unprovoked seizure, these are factors that might favour early treatment.
Children and parents also need education on how to avoid precipitating factors. In one study, a lower relapse rate (uninfluenced by AED therapy) was observed in a group educated to avoid such factors.7 If drugs are prescribed, many patients and caregivers need help in managing prescriptions to minimize the risk of adverse effects.8