When to treat childhood seizures

The issues of when to initiate and discontinue antiepileptic drugs are reviewed. The majority of children who present with a first unprovoked seizure will not experience further seizures. At particularly low risk (20-30%) are children with an idiopathic first seizure and a normal electroencephalogram (EEG). Risk factors for recurrence include a remote symptomatic etiology and an abnormal EEG. The morbidity of seizures is reviewed and compared with the morbidity of antiepileptic drug therapy. The author recommends that in most cases drug therapy should not be initiated after a single seizure even if risk factors are present. The subject of when to withdraw drug therapy in children with epilepsy after a seizure free interval is then addressed. The majority of children who are seizure free for 2 or more years on medications will remain so when medications are withdrawn. Prognostic factors include etiology, EEG prior to discontinuation of medication and age of onset. A 2-year-seizure-free interval appears to be sufficient. Most children who are seizure free on medications should have at least one attempt at medication withdrawal.