What medications are used to treat jerky movements or seizures, specifically what antiepileptic drugs (AEDs) are prescribed?

Medications for Jerky Movements and Seizures

For convulsive epilepsy, standard first-line antiepileptic drugs include carbamazepine, phenobarbital, phenytoin, and valproic acid, with carbamazepine preferred for partial onset seizures and valproic acid for generalized seizures. 1

First-Line Treatment Selection by Seizure Type

For Partial Onset Seizures

• Carbamazepine should be preferentially offered to children and adults with partial onset seizures 1
• Lamotrigine is equally suitable as first-line treatment for partial seizures 2
• Levetiracetam may be considered as an alternative first-line option, particularly if there is no history of psychiatric disorder 3, 2
• Oxcarbazepine is also recommended as first-line therapy 3

For Generalized Tonic-Clonic Seizures

• Sodium valproate is the first-line treatment for generalized onset seizures 1, 2
• Lamotrigine and levetiracetam are suitable alternatives, especially for women of childbearing potential where valproate should be avoided due to teratogenicity 2, 4

For Jerky Movements (Myoclonus/Chorea)

• Dopamine antagonists are usually effective for symptomatic treatment of chorea 1
• Glucocorticoids combined with immunosuppressive agents (azathioprine, cyclophosphamide) may be used when jerky movements are related to underlying inflammatory conditions 1
• Clonazepam, gabapentin, levetiracetam, and valproate are antiseizure drugs that can treat myoclonic jerks 5

Emergency/Acute Seizure Management

Status Epilepticus Treatment Algorithm

1. First-line: Intravenous benzodiazepines 6
2. Second-line (if seizures persist): Choose one of the following 1, 6:
   • Fosphenytoin: 18-20 PE/kg IV at maximum rate of 150 PE/min 6
   • Levetiracetam: 30-50 mg/kg IV at 100 mg/min 6
   • Valproate: 20-30 mg/kg IV at maximum rate of 10 mg/kg/min 1, 6

The ESETT trial demonstrated no significant difference in efficacy between these three second-line agents, with seizure cessation rates of 47% for levetiracetam, 45% for fosphenytoin, and 46% for valproate 6

Safety Considerations for Second-Line Agents

• Levetiracetam has the lowest rate of life-threatening hypotension (0.7%) and intubation (20%) 6
• Fosphenytoin carries higher risk of hypotension (3.2%) and intubation (26.4%) 6
• Valproate has intermediate safety profile with 1.6% hypotension rate and 16.8% intubation rate 6

Important Treatment Principles

When NOT to Start Treatment

• Antiepileptic drugs should not be routinely prescribed after a first unprovoked seizure 1
• Treatment should be strongly considered after 2 unprovoked seizures or after 1 unprovoked seizure with high-risk features (sleep occurrence, epileptiform EEG activity, structural brain lesion) 3

Monotherapy Preference

• Monotherapy with a single antiepileptic drug should be offered 1
• Approximately 60-70% of patients achieve seizure freedom with appropriate monotherapy 3

Special Populations

Women of Childbearing Potential:

• Valproic acid should be avoided if possible due to teratogenicity 1, 2
• Folic acid should routinely be taken when on antiepileptic drugs 1
• Antiepileptic drug monotherapy at minimum effective dose is preferred 1
• Carbamazepine reduces effectiveness of hormonal contraceptives; alternative contraception methods should be used 7

Resource-Limited Settings:

• Phenobarbital should be offered as first option if availability can be assured, given acquisition costs 1

Common Pitfalls to Avoid

• Do not overlook underlying causes: While administering antiseizure medications, simultaneously search for treatable causes including hypoglycemia, hyponatremia, hypoxia, drug toxicity, CNS infection, stroke, or hemorrhage 1, 6
• Recognize non-convulsive status epilepticus: This may require EEG monitoring and can be missed clinically 6
• Avoid phenytoin/phenobarbital in patients with intellectual disability: When available, consider valproic acid or carbamazepine instead due to lower risk of behavioral adverse effects 1
• Monitor for drug interactions: Carbamazepine is a potent CYP3A4 inducer and reduces levels of many concomitant medications 7
• Phenobarbitone generally performs worse than other treatments for time to treatment withdrawal, making it a less desirable option despite low cost 2

Discontinuation Considerations

• Discontinuation of antiepileptic drug treatment should be considered after 2 seizure-free years 1
• The decision should involve consideration of clinical, social, and personal factors with patient and family involvement 1