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J R Soc Med. 2004 April; 97(4): 208.
PMCID: PMC1079376

When to start drug therapy in epilepsy

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

References

1. Newton RW. When is drug treatment not necessary in epilepsy? Factors that should influence the decision to prescribe. J R Soc Med 2004;97: 15-19 [PMC free article] [PubMed]
2. Hauser WA, Anderson VE, Loewenson RB, McRoberts SM. Seizure recurrence after a first unprovoked seizure. N EnglJMed 1982;307: 522-8 [PubMed]
3. Berg AT, Shinnar S, Levy SR, Testa FM. Status epilepticus in children with newly diagnosed epilepsy. Ann Neurol 1999;45: 618-23 [PubMed]
4. Madhusudanan M. First unprovoked seizure to treat or not to treat? J Assoc Physicians India 2000;48: 519-24 [PubMed]
5. Scotoni AE, Manreza ML, Guerreiro MM. Recurrence after a first unprovoked cryptogenic/idiopathic seizure in children: a prospective study from São Paulo, Brazil. Epilepsia 2004;45: 166-70 [PubMed]
6. Hui AC, Tang A, Wong KS, Mok V, Kay R. Recurrence after a first untreated seizure in the Hong Kong Chinese population. Epilepsia 2001;42: 94-7 [PubMed]
7. Wolf P. Non-medical treatment of first epileptic seizures in adolescence and adulthood. Seizure 1995;4: 87-94 [PubMed]
8. Kumar S. Adverse effects due to poor patient understanding of anti-epileptic medication prescriptions. Indian Pediatr 2003;40: 801-2 [PubMed]

Articles from Journal of the Royal Society of Medicine are provided here courtesy of Royal Society of Medicine Press