What are the first-line medications for a child with new onset seizure?

From the Guidelines

For a child with new onset seizure, the first-line medication should be monotherapy with any of the standard antiepileptic drugs, with phenobarbital being the first option if availability can be assured, as recommended by the World Health Organization 1. The choice of medication depends on the seizure type, patient's age, comorbidities, and potential side effects.

• For convulsive epilepsy, monotherapy with any of the standard antiepileptic drugs (carbamazepine, phenobarbital, phenytoin, and valproic acid) is recommended 1.
• Given the acquisition costs, phenobarbital should be offered as a first option if availability can be assured 1.
• If available, carbamazepine should be preferentially offered to children and adults with partial onset seizures 1. It's essential to note that antiepileptic drugs should not be routinely prescribed to adults and children after a first unprovoked seizure 1. Regular monitoring of drug levels, liver function, complete blood count, and electrolytes is essential, especially during initial treatment. Treatment should continue for at least 2 years after the last seizure before considering discontinuation, which should always be done gradually under medical supervision 1. In the case of febrile seizures, neither continuous nor intermittent anticonvulsant therapy is recommended for children with 1 or more simple febrile seizures, as the potential toxicities associated with these agents outweigh the relatively minor risks associated with simple febrile seizures 1.

From the FDA Drug Label

Oxcarbazepine tablets are prescription medicine used: • alone or with other medicines to treat partial-onset seizures in adults • alone to treat partial-onset seizures in children 4 years and older • with other medicines to treat partial-onset seizures in children 2 years and older

The effectiveness of topiramate as an adjunctive treatment for pediatric patients ages 2 to 16 years with partial onset seizures was established in a multicenter, randomized, double-blind, placebo-controlled trial, comparing topiramate and placebo in patients with a history of partial onset seizures, with or without secondarily generalized seizures.

The efficacy of divalproex sodium in reducing the incidence of complex partial seizures (CPS) that occur in isolation or in association with other seizure types was established in two controlled trials

The first-line medications for a child with new onset seizure are:

• Oxcarbazepine for children 4 years and older for partial-onset seizures, and for children 2 years and older when used with other medicines.
• Topiramate for pediatric patients ages 2 to 16 years with partial onset seizures as an adjunctive treatment.
• Valproate for complex partial seizures that occur in isolation or in association with other seizure types. 2, 3, 4

From the Research

First-Line Medications for New Onset Seizure in Children

• The first-line medications for a child with new onset seizure depend on the type of seizure, with options including:
  • Carbamazepine or lamotrigine for focal onset seizures 5, 6
  • Sodium valproate for generalized onset seizures 5, 6, 7
• Levetiracetam is also considered a suitable alternative for both focal and generalized onset seizures 5, 6
• The choice of medication should be based on individual patient factors, such as the presence of EEG epileptiform discharges, brain imaging abnormalities, or prior brain trauma 8

Considerations for Specific Seizure Types

• For generalized tonic-clonic seizures, lamotrigine, levetiracetam, and topiramate are as effective as valproate 7
• For absence seizures, valproate and ethosuximide are considered the best options 7
• For neonatal seizures, phenobarbital is recommended as the first-line antiseizure medication, unless channelopathy is likely the cause, in which case phenytoin or carbamazepine may be used 9

Adverse Events and Treatment Failure

• The most commonly reported adverse events across all medications include drowsiness/fatigue, headache or migraine, gastrointestinal disturbances, dizziness/faintness, and rash or skin disorders 5, 6
• Treatment failure rates vary depending on the medication and seizure type, with lamotrigine and levetiracetam generally showing lower treatment failure rates for focal onset seizures 5