Treatment of Rolandic Epilepsy (Benign Childhood Epilepsy with Centrotemporal Spikes)
Treatment with antiseizure medications is NOT routinely required for children with Rolandic epilepsy who have infrequent, brief nocturnal seizures, as this condition is self-limited and resolves by mid-adolescence in nearly all cases. 1, 2
When Treatment Can Be Withheld
The majority of children with Rolandic epilepsy do not require treatment, as seizures are typically infrequent, brief, and self-limited. 3, 2
Rolandic epilepsy is "sufficiently characteristic to be diagnosed clinically or through specific EEG patterns and usually does not require imaging" or aggressive intervention. 1
The disorder is marked by nocturnal generalized tonic-clonic seizures and brief diurnal simple partial seizures with facial clonic activity, dysphasia, and drooling that almost always stop by age 16 years. 2
When seizures are infrequent (1-2 per year) and occur only at night without significant impact on the child's daily functioning, observation without medication is a reasonable approach. 3, 2
When Treatment Should Be Considered
Treatment is justified when:
Seizures are frequent enough to interfere with school performance, sleep quality, or family functioning. 4
Daytime seizures occur that could pose safety risks or cause social embarrassment. 2
There are concerns about evolution to atypical forms of the syndrome. 4
Associated cognitive difficulties or learning problems are present that might benefit from seizure control. 4, 5
The child has experienced more than 4 seizures before treatment initiation, as this subset may have more refractory disease. 5
Recommended Medications When Treatment Is Needed
If you decide to treat, levetiracetam or sulthiame are the recommended first-line agents based on existing evidence:
Levetiracetam has demonstrated efficacy with an excellent safety profile, with all treated children in case series remaining seizure-free without reported side effects. 3, 4
Sulthiame is also recommended based on available evidence, though data remains limited. 4
Carbamazepine is effective for seizure control but should be used cautiously, as initial treatment with non-carbamazepine medications may be associated with better outcomes in certain subsets. 5
Clonazepam effectively suppresses the characteristic centrotemporal spikes on EEG (75% disappearance rate within 4 weeks), though spike suppression does not correlate with seizure control. 6
Valproate and carbamazepine are less effective at suppressing the EEG discharges (10% and 0% respectively). 6
Critical Clinical Pitfalls
Do not confuse EEG spike frequency with seizure severity—the amount of Rolandic discharges does not correlate with seizure incidence, so treatment decisions should be based on clinical seizure frequency, not EEG findings. 6
Approximately 21% of children with Rolandic epilepsy require two medications for adequate control, particularly those with more frequent pre-treatment seizures (>4 seizures) or comorbid conditions like ADHD, tics, or learning disabilities. 5
Recent evidence suggests Rolandic epilepsy may not be as uniformly benign as previously assumed, with some children experiencing negative cognitive consequences that might benefit from treatment. 4
When treatment is elected, seizures are usually easily controlled, but the decision to treat should weigh the benign natural history against potential medication side effects. 2
Practical Management Algorithm
For infrequent nocturnal seizures (1-2/year): Observation without medication, with parent education about the benign prognosis and expected resolution by mid-adolescence. 3, 2
For frequent seizures or daytime events: Initiate levetiracetam as first-line therapy given its efficacy and favorable side effect profile. 3, 4
For treatment failures: Consider adding a second agent, as approximately 1 in 5 children will require dual therapy. 5
Monitor for: Associated learning difficulties, attention problems, or behavioral issues that may warrant treatment even with infrequent seizures. 4, 5