eMedicine Specialties > Neurology > Seizures and Epilepsy
Absence Seizures: Treatment & Medication
Updated: Apr 7, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
Treatment involves antiepileptic drugs (AEDs). Once the proper diagnosis (ie, of the specific epilepsy syndrome) is made, the likelihood of other coexistent seizure types, such as myoclonic or tonic-clonic, should be considered and an appropriate medication selected. Since altered awareness occurs with even brief bursts of spike-wave paroxysms on EEG, treatment should be titrated to suppressing all epileptiform activity.37
- Ethosuximide (Zarontin) is effective only against absence seizures.
- Valproic acid (Depakene, Depacon) and divalproex sodium (Depakote, Depakote ER) are considered broad-spectrum AEDs because they are effective against absence, myoclonic, tonic-clonic, and partial seizures.
- Symptomatic generalized epilepsies are often refractory to first-line AEDs. Lamotrigine (Lamictal) and topiramate (Topamax) are approved by the FDA as adjunctive therapy for the generalized seizures of Lennox-Gastaut syndrome in adult and pediatric patients (³ 2 y). Clonazepam (Klonopin, felbamate (Felbatol), topiramate, and the ketogenic or medium-chain triglyceride diet have been attempted to reduce seizure frequency. However, these adjunctive therapies have limited efficacy.
- Some AEDs can aggravate seizures, especially in cryptogenic or symptomatic generalized epilepsies.38 Treatment with carbamazepine (Tegretol, Tegretol XR, Carbatrol)39,40 and oxcarbazepine (Trileptal)41 has been associated with the exacerbation of absence seizures. Gabapentin (Neurontin) is ineffective against absence seizures42 and tiagabine (Gabitril) and vigabatrin (Sabril) have been associated with the exacerbation of absence or myoclonic seizures in some patients.43,44
Consultations
All patients with suspected absence seizures should be examined by a neurologist who has expertise in diagnosing epileptic syndromes. Patients with refractory seizures, especially those with symptomatic epilepsies, may need to be referred to an epileptologist for prolonged EEG video monitoring and medication adjustments.
Diet
Patients with medically intractable seizures may be tried on a ketogenic45 or medium-chain triglyceride diet46 . Although these diets are difficult to maintain, there is evidence for their effectiveness.47 Children in whom such diets are being considered should be referred to a center with specialized dietary services.
Activity
Physical activity should not be restricted any more than necessary. Activities in which a seizure might pose a threat, such as swimming or rock climbing, may be allowed with appropriate supervision. A child with epilepsy should not be unnecessarily handicapped. Patients with uncontrolled absence seizures should not be allowed to drive. The situation may be unclear when the patient's clinical seizures are controlled but the EEG still shows some spike-wave activity.
Medication
The decision to start antiepileptic medication must be made with great care. Most AEDs are relatively toxic and can have sedative and cognitive side effects. Children with absence seizures may need to be on medication for many years, and in some for life. EEG can usually confirm the diagnosis and the presence of spontaneous seizures can be documented on routine EEG or with longer recordings (ie, 24-hour ambulatory EEG or EEG video monitoring).
Most AEDs are not effective against absence seizures. Also, many patients have both absence and generalized convulsive (myoclonic and generalized tonic-clonic) seizures and need an AED with efficacy for both. Only 2 first-line AEDs have FDA approval to be indicated for absence seizures: ethosuximide and valproic acid. Ethosuximide has efficacy for absence only and valproic acid has efficacy for absence, generalized tonic-clonic, and myoclonic seizures.
Of the newer AEDs, lamotrigine, topiramate, and levetiracetam have been shown to have efficacy against seizures in idiopathic generalized epilepsy48,49 and have received FDA approval to be indicated for adjunctive therapy of generalized tonic-clonic seizures in idiopathic generalized epilepsy in children 2 and older (for lamotrigine and topiramate) and in children 6 and older (for levetiracetam). Lamotrigine and topiramate are also approved as adjunctive therapy in Lennox-Gastaut syndrome in children 2 years and older. Topiramate has also received FDA approval as initial monotherapy for generalized tonic-clonic seizures in children 10 years and older with idiopathic generalized epilepsy. Studies have shown these medications to have anti-absence efficacy, but the data are incomplete.50
Antiepileptics
If the patient has only absence seizures, then ethosuximide (Zarontin) is an appropriate medication. This may be the case for patients with childhood absence epilepsy. Ethosuximide may also be used in conjunction with an anticonvulsive AED, such as phenytoin (Dilantin) for patients at risk of tonic-clonic seizures in whom valproic acid is contraindicated.
Lamotrigine (Lamictal)
Triazine derivative used in neuralgia. Inhibits release of glutamate and inhibits voltage-sensitive sodium channels, leading to stabilization of neuronal membrane.
Adult
Monotherapy:
Initial: 50-100 mg/day PO bid
Maintenance: 100-400 mg/day PO divided in 1-2 doses, not to exceed 500 mg/day
Adjunct therapy with valproic acid:
Initial dose: 25 mg PO qod
Maintenance: 50-200 mg/day in 1-2 divided doses, not to exceed 200 mg/day
Pediatric
<2 years: Not established
2-12 years:
Added to regimens Weeks 1-2: 0.6 mg/kg/day PO divided q12h, rounded down to nearest 5 mg (ie, to nearest whole tablet)
Weeks 3-4: 1.2 mg/kg/day PO divided q12h, rounded down to nearest 5 mg
Maintenance: 5-15 mg/kg/day PO; not to exceed 400 mg/day PO divided q12h
To achieve maintenance dose, increase doses q1-2wk as follows:
Calculate 1.2 mg/kg/day and round down to nearest 5 mg; add this amount to previously administered daily dose
Concomitant therapy with valproic acid:
Weeks 1-2: 0.15 mg/kg/day PO qd or divided bid, rounded down to nearest 5 mg
If initial calculated daily dose is 2.5 to 5 mg, take 5 mg on alternate days for first 2 wk
Weeks 3-4: 0.3 mg/kg/day PO qday or divided bid, rounded down to nearest 5 mg
Maintenance: 1-5 mg/kg/day PO qday or divided bid, not to exceed 200 mg/day
To achieve maintenance dose, increase doses q1-2wk as follows:
Calculate 0.3 mg/kg/day, and round down to nearest 5 mg; add amount to previously administered qday dose
Added to AED regimens that do NOT include carbamazepine, phenytoin, phenobarbital, primidone, or valproate:
Weeks 1-2: 0.3 mg/kg/day PO qday or divided bid, rounded down to nearest 5 mg
Weeks 3-4: 0.6 mg/kg/day PO divided q12h, rounded down to nearest 5 mg
Maintenance: 4.5-7.5 mg/kg/day PO; not to exceed 300 mg/day PO divided q12h
To achieve maintenance dose, increase doses q1-2wk as follows:
Calculate 0.6 mg/kg/day and round down to nearest 5 mg; add this amount to previously administered daily dose
>12 years:
Added to regimens that include carbamazepine, phenytoin, phenobarbital, or primidone:
Weeks 1-2: 50 mg/day PO
Weeks 3-4: 100 mg/day PO divided bid
Maintenance: 300-500 mg/day PO divided bid; to achieve maintenance, increase doses by 100 mg/day q1-2wk
Concomitant therapy with valproic acid:
Weeks 1-2: 25 mg PO every other day
Weeks 3-4: 25 mg PO qday
Maintenance: 100-400 mg/day PO qday or divided bid
To achieve maintenance dose, may increase by 25-50 mg/day q1-2wk
Added to AED regimens that do NOT include carbamazepine, phenytoin, phenobarbital, primidone, or valproate:
Weeks 1-2: 25 mg PO qday
Weeks 3-4: 50 mg PO qday
Maintenance: 225-375 mg/day PO qday or divided q12h
Acetaminophen increases renal clearance of medication, decreasing effects; similarly, carbamazepine, phenobarbital, and phenytoin increase lamotrigine metabolism causing a decrease in lamotrigine levels; succinimide anticonvulsants (eg, methsuximide, phensuximide) decrease lamotrigine levels; estrogen-containing oral contraceptives increase elimination (most patients require up to a 2-fold dose increase of lamotrigine); rifampin decreases lamotrigine levels; administration of valproic acid with lamotrigine increases half-life and serum levels
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in impaired renal or hepatic function
Ethosuximide (Zarontin)
Succinimide AED effective only against absence seizures. No effect on generalized tonic-clonic, myoclonic, atonic, or partial seizures. Mechanism of action based on reducing current in T-type calcium channels on thalamic neurons. Spike-and-wave pattern during petit mal seizures thought to be initiated in thalamocortical relays by activation of these channels. Available in large 250-mg capsules, which may be difficult for some children to swallow, and as syrup (250 mg/5 mL).
Adult
250 mg PO bid; increase by 250-mg increments q4-7d until seizures controlled or maximum daily dose reached; not to exceed 1.5 g/day
Pediatric
<6 years: 15 mg/kg/day PO divided bid initially; initial dose not to exceed 250 mg; may increase to effect q4-14d
>6 years: Administer as in adults
Maintenance dose: 15-40 mg/kg/day PO divided bid
Generally minimal; enzyme-inducing drugs (eg, PHT, carbamazepine, phenobarbital) may lower levels by 15-25%; valproic acid may elevate levels; has weak enzyme-inhibiting effect, usually insignificant with respect to metabolism of other drugs
Documented hypersensitivity; blood dyscrasias; renal or hepatic disease
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Blood dyscrasias may occur and may be fatal (monitor CBC); caution in hepatic or renal disease; abrupt withdrawal may precipitate absence status
Valproic acid (Depakene, Depacon, Depakote, Depakote ER)
DOC for patients who have absence and generalized tonic-clonic and/or myoclonic seizures; aliphatic compound, carboxylic acid. Discovery was serendipitous; used as solvent potential AEDs, and all test compounds seemed to work. Mechanism of action not known but believed to be related to ability to increase brain GABA. May inhibit rapid opening of sodium channels and block T-type calcium channels.
Depakene available as syrup (250 mg/5 mL), 250- or 500-mg capsules, and IV preparation (100 mg/5 mL; Depacon). Divalproex sodium (Depakote) available as 250- or 500-mg tab and 125-mg capsule (Depakote Sprinkles), which can be opened and mixed with food.
Syrup rapidly absorbed through the stomach and produces gastric irritation. Rapidly produces high serum levels and may cause peak-dose toxicity. Must be given in 3-4 divided doses. Other oral preparations absorbed more slowly from GI tract and better tolerated. Because of slower absorption, some patients who have achieved control may be treated with bid dosing.
Highly protein bound; protein binding is level dependent. At 40 mg/mL, 90% bound, but at 130 mg/mL, 80% bound. Therefore, as total level increases from 40 to 130 mg/mL, free level increases from 4 to 26 mg/mL. Therapeutic range originally 50-100 mg/mL; patients with hard-to-control seizures may require higher level.
Depakote ER is extended-release product intended for once-a-day oral administration. When converting from Depakote to Depakote ER, dose 8-20% higher than total daily dose of Depakote is needed. IV Depacon may be given as maintenance therapy; amount mixed with at least 50 mL of compatible diluent and infused at rate not >20 mg/kg/min over at least 60 min; research ongoing concerning IV loading at more rapid rates.
Adult
10-15 mg/kg/day PO initially; increase by 5-10 mg/kg/day weekly until seizures controlled or adverse effects develop; not to exceed 60 mg/kg/day divided tid/qid
Pediatric
15 mg/kg/day PO initial dose, increasing by 5-10 mg/kg/day weekly until seizures controlled or adverse effects develop; maximum recommended dosage 60 mg/kg/day divided tid/qid; for select patients with complete control, bid dosing may be tried
Cimetidine, salicylates, felbamate, and erythromycin may increase toxicity; rifampin, phenytoin, phenobarbital, and carbamazepine may significantly reduce levels; in children, salicylates decrease protein binding and metabolism; carbamazepine may result in variable changes of carbamazepine concentrations with possible toxicity or loss of seizure control; may increase diazepam and ethosuximide toxicity (monitor closely); may increase phenobarbital and phenytoin levels; may displace warfarin from protein-binding sites (monitor coagulation tests) and can displace phenytoin, resulting in transient increase in free levels; may increase zidovudine levels in HIV-seropositive patients
Documented hypersensitivity; hepatic disease or dysfunction; because of teratogenicity, first trimester of pregnancy and in women of childbearing age who are not on adequate birth control, unless it is clearly the most effective drug for a woman planning pregnancy and aware of risks
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Hepatic dysfunction may occur (more common in children taking multiple AEDs) during first 6 mo of therapy, and may be fatal; assess liver function test (LFT) results before therapy and at frequent intervals during first 6 mo; clinical symptoms (loss of seizure control, malaise, weakness, lethargy, facial edema, anorexia, vomiting) may precede LFT abnormalities; hyperammonemia reported and may occur despite normal LFTs; may cause lethargy or coma; when asymptomatic elevations of ammonia are present, more frequent monitoring indicated; carnitine supplementation may be beneficial in addition to platelet dysfunction, thrombocytopenia may occur and is associated with high doses
Pancreatitis may occur, even after several years of therapy; perform appropriate tests in patients with malabsorption, abdominal pain, or other GI symptoms; spina bifida in 1-2% of children born to women taking valproic acid during first 12 wk of pregnancy; women planning to become pregnant should take folic acid 1-5 mg/day, and consider crossing over to ethosuximide before conception; for women who have generalized tonic-clonic seizures, ethosuximide and anticonvulsant AED can be used
More on Absence Seizures |
| Overview: Absence Seizures |
| Differential Diagnoses & Workup: Absence Seizures |
 Treatment & Medication: Absence Seizures |
| Follow-up: Absence Seizures |
| Multimedia: Absence Seizures |
| References |
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Further Reading
Keywords
absence seizure, petit mal seizures, generalized seizures, idiopathic generalized epilepsy, symptomatic generalized epilepsy, seizure treatment, epilepsy treatment, idiopathic generalized epilepsies, childhood absence epilepsy, pyknolepsy, juvenile absence epilepsy, juvenile myoclonic epilepsy, impulsive petit mal seizures, typical absence seizures, symptomatic generalized epilepsies, nonpyknoleptic seizures, spanioleptic absence seizures
