The Treatment Decision

'The decision to treat is highly individualized, weighing the risks of treatment against the risks of seizures.'

When a child or adult experiences a single seizure, or appears at the doctor’s office with a history of questionable events that may or may not have been seizures, the first issue is to determine what happened, whether a seizure actually took place, of what type and duration it was, the possible cause, and the future prognosis.

Once this information is gathered, the next question is whether to treat the underlying condition (if one has been identified and if it is treatable), or whether to treat the symptoms by prescribing antiepileptic (or seizure-preventing) drugs.

Unless the EEG is clearly abnormal, thus increasing the likelihood of subsequent seizures, physicians tend to wait until a second or even third seizure occurs before beginning antiepileptic medication. They do so because studies show that an otherwise normal child who has had a single seizure has a relatively low (15 percent) risk of a second one. Once the second has occurred, the risk of subsequent seizures is substantially increased.

On the other hand, the risk of another seizure for a child who is neurologically abnormal, or whose EEG is abnormal, may be as high as 50 to 60 percent.

In determining whether to treat, physicians consider the risk-benefit ratio, which varies according to the age of the patient and his or her activity level. Waiting to see whether another generalized tonic-clonic seizure occurs is less risky for a child living in a sheltered home environment than it is for a salesman who lives most of his life driving a car, or an elderly person with brittle bones. On the other hand, antiepileptic drugs have side effects which, while generally mild, can in some cases include liver damage and potentially fatal rashes and blood disorders. Thus the decision to treat becomes a highly individualized one in which the risks of the treatment are weighed against the risks of the seizures.

There is debate about whether or not children with febrile (fever caused) seizures should be placed on antiepileptic drugs. Current opinion favors withholding therapy for most of these children, since side effects of the medication may cause more problems than recurrent febrile convulsions. There may be instances, however, when treatment is prescribed.