The goal of antiseizure medication is to reduce the frequency of seizures without untoward adverse effects. The ideal therapy will result in no seizures and no adverse effects. Medications should be chosen based on the seizure type, epilepsy syndrome, etiology, medication adverse effect profile, and the child’s other medical comorbidities. Certain antiseizure medications may worsen specific seizure types, such as exacerbation of absence seizures by sodium channel blockers such as oxcarbazepine, carbamazepine, or phenytoin.
Prophylactic medication is often not initiated after a first unprovoked seizure, unless there are factors suggesting a high likelihood of recurrence, such as specific syndromes or etiologies. Children who present in status epilepticus are more likely to be administered antiseizure medication due to increased risk of subsequent prolonged seizures; however, in such cases, provision of a home rescue medication is also needed.
There is generally overreliance on medication levels. Medications are generally considered to be therapeutic if the child is having no seizures and no adverse effects. Levels should be considered if there are ongoing seizures despite high doses, if one is adding a new medication that can have pharmacokinetic interactions with another drug, or to check compliance.
If medication levels are assessed, they should be obtained during trough level times, just before the next dose being given. Random drug levels often result in inappropriate reduction of medication doses with breakthrough seizures. Certain medications do require periodic monitoring of blood counts and liver enzyme levels.