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There are 4 treatment options for epilepsy: medication, vagus nerve stimulator, ketogenic diet, and epilepsy surgery. Unlike other chronic disease states for which nonpharmacologic therapy may be considered first line, in patients with epilepsy, medication is first-line therapy. Choosing the appropriate medication at the appropriate dose is crucial, as patients are considered to have refractory epilepsy if they fail 2 antiepileptic drugs (AEDs) that are otherwise appropriate for the type of seizure and therapeutic dose. Once refractory, seizures become more difficult to control with medication alone, and, therefore, the first and second choice of anticonvulsant is important. It is, thus imperative to know what type of seizure(s) the patient is having, as it may affect the choice of AED. This chapter will focus on the when, how, and what to choose as initial AED therapy in a patient with epilepsy, in addition to other important factors that may assist the pediatrician in caring for a patient with epilepsy.


The typically recognized definition of epilepsy is 2 unprovoked seizures separated by 24 hours, as at this point the recurrence risk for further seizures is high. For this reason, the general rule is to begin AED therapy once a patient has epilepsy and not after the first seizure. However, therapy after a single unprovoked seizure is debated, as an additional definition of epilepsy is 1 unprovoked seizure plus a high probability of further seizures. Some examples of this higher probability of future seizures would include seizures following a stroke or if a patient has a structural brain lesion that may predispose the patient to future seizures. Seizures are common, affecting 10% of the population, but only 1% will progress to having epilepsy. Although AED treatment after an initial seizure may help reduce the risk of having a second seizure, there is no proven benefit on the long-term prognosis of future epilepsy. In any case, the decision to treat with drug therapy is individualized.


There are almost 30 US Food and Drug Administration (FDA)–approved medications from which to choose when deciding to initiate therapy. To make the best decision, one needs to consider the following: What type of seizure is this child having? What other chronic diseases does the patient have? Is the patient on other chronic medications? What side effects would be unacceptable? Can the child swallow pills, or is a liquid needed?

Broad Versus Narrow Spectrum

An electroencephalogram (EEG) will help classify what type of seizure the patient is having, specifically generalized or focal, which can help guide choosing the first AED (Table 554-1). This distinction is important because the broad-spectrum AEDs will be beneficial for generalized seizures, as they cover almost all seizure types, whereas the narrow-spectrum AEDs will treat only focal seizures or, in the case ...

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