Is Wellbutrin (bupropion) contraindicated in a patient with a history of febrile seizure at age 4?

Wellbutrin is NOT Contraindicated for a History of Febrile Seizure at Age 4

A simple febrile seizure in childhood does not constitute a contraindication to bupropion (Wellbutrin) use, as these seizures are benign, self-limited events that do not increase epilepsy risk and do not represent an underlying seizure disorder. 1, 2

Understanding the FDA Contraindication

The FDA explicitly states that bupropion is contraindicated in patients with seizure disorder 3. However, this contraindication applies to patients with:

• Active epilepsy or recurrent unprovoked seizures 3
• Current seizure disorders requiring treatment 3

A remote history of simple febrile seizures does NOT constitute a "seizure disorder" and therefore does not meet FDA contraindication criteria 1, 2.

Why Simple Febrile Seizures Are Different

Simple febrile seizures are fundamentally distinct from epilepsy:

• They carry approximately 1% risk of developing epilepsy by age 7 years—identical to the general population 1, 2
• Even with multiple risk factors (age <12 months at first seizure, multiple febrile seizures, family history of epilepsy), the epilepsy risk only increases to 2.4% by age 25 years 1, 2
• Simple febrile seizures cause no structural brain damage, no decline in IQ, and no long-term neurological sequelae 1
• The American Academy of Pediatrics explicitly states these seizures have excellent prognosis with no adverse neurocognitive effects 1, 2

Clinical Decision Framework

For a patient with remote simple febrile seizure at age 4:

1. Confirm the seizure was truly "simple" (generalized, <15 minutes duration, single episode in 24 hours, occurred with fever ≥100.4°F) 1
2. Verify no subsequent unprovoked seizures have occurred since childhood 1, 2
3. If both criteria met: Bupropion is NOT contraindicated 3

Red flags that WOULD contraindicate bupropion:

• History of complex febrile seizures (focal features, >15 minutes, recurrent within 24 hours) 1
• Any unprovoked seizures after the febrile seizure episode 3
• Diagnosis of epilepsy at any point 3
• Current use of antiepileptic medications 3

Important Caveats About Bupropion and Seizure Risk

While not contraindicated in this scenario, clinicians should understand bupropion's seizure risk:

• Bupropion lowers seizure threshold in all patients 4, 5
• Seizure incidence is dose-dependent, with rates comparable to other antidepressants when kept ≤450 mg/day in divided doses 5
• Nearly half of patients who experienced seizures on bupropion had identifiable risk factors that were overlooked 6
• The drug should be used with caution (not avoided) in patients with clinical factors that may increase seizure risk 4

Actual contraindications for bupropion include:

• Active seizure disorder 3
• Bulimia or anorexia nervosa (higher seizure incidence) 3
• Abrupt discontinuation of alcohol, benzodiazepines, barbiturates, or antiepileptic drugs 3

Practical Prescribing Approach

If prescribing bupropion to this patient:

• Start with standard dosing (150 mg daily, titrating to 300 mg daily as tolerated) 3
• Maintain total daily dose ≤450 mg to minimize seizure risk 5
• Counsel patient about seizure risk and warning signs 7
• Monitor more carefully during the first 2 weeks of treatment when most serious adverse reactions occur 6
• Avoid concurrent medications that lower seizure threshold 3

The key distinction: A childhood febrile seizure is a provoked seizure in response to fever, not an unprovoked seizure indicating underlying epilepsy 1, 2. This patient does not have a "seizure disorder" as defined by the FDA contraindication 3.