management of childhood-onset typical absence epilepsy

Last edited 09/2018

The most effective treatments are:

• sodium valproate - may also control the tonic-clonic and myoclonic seizures in the syndrome
• ethosuximide - may control the myoclonic seizures; however will not control tonic-clonic seizures
• lamotrigine - may control all seizure types

Note that phenytoin, carbamazepine and vigabatrin may exacerbate absences, especially if associated with myoclonus, and so should be avoided (1,2).

Pharmacological treatment of absence seizures

First-line treatment in children, young people and adults with absence seizures

• ethosuximide or sodium valproate should be offered as first-line treatment to children, young people and adults with absence seizures. If there is a high risk of generalised tonic-clonic (GTC) seizures, then offer sodium valproate first, unless it is unsuitable. Follow the MHRA safety advice on sodium valproate
• offer lamotrigine if ethosuximide and sodium valproate are unsuitable, ineffective or not tolerated. Follow the MHRA safety advice on sodium valproate

Adjunctive treatment in children, young people and adults with absence seizures

• if two first-line AEDs are ineffective in children, young people and adults with absence seizures, consider a combination of two of these three AEDs as adjunctive treatment:
  • ethosuximide, lamotrigine or sodium valproate. Follow the MHRA safety advice on sodium valproate
• if adjunctive treatment is ineffective or not tolerated, discuss with, or refer to, a tertiary epilepsy specialist and consider clobazam, clonazepam, levetiracetam, topiramate or zonisamide
• do not offer carbamazepine, gabapentin, oxcarbazepine, phenytoin, pregabalin, tiagabine or vigabatrin

Reference:

1. Drug and Therapeutics Bulletin (2001), 39 (2), 12-16.
2. Parker APJ et al (1998). Inappropriate use of carbamazepine and vigabatrin in typical absence seizures. Dev Med Child Neurol, 40, 517-519.
3. NICE (April 2018). Epilepsies: diagnosis and management