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Treatment of Typical Absence Seizures and Related Epileptic Syndromes

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Abstract

Typical absences are brief (seconds) generalised seizures of sudden onset and termination. They have 2 essential components: clinically, the impairment of consciousness (absence) and, generalised 3 to 4Hz spike/polyspike and slow wave discharges on electroencephalogram (EEG). They differ fundamentally from other seizures and are pharmacologically unique. Their clinical and EEG manifestations are syndrome-related. Impairment of consciousness may be severe, moderate, mild or inconspicuous. This is often associated with motor manifestations, automatisms and autonomic disturbances. Clonic, tonic and atonic components alone or in combination are motor symptoms; myoclonia, mainly of facial muscles, is the most common. The ictal EEG discharge may be consistently brief (2 to 5 seconds) or long (15 to 30 seconds), continuous or fragmented, with single or multiple spikes associated with the slow wave. The intradischarge frequency may be constant or may vary (2.5 to 5Hz).

Typical absences are easily precipitated by hyperventilation in about 90% of untreated patients. They are usually spontaneous, but can be triggered by photic, pattern, video games stimuli, and mental or emotional factors.

Typical absences usually start in childhood or adolescence. They occur in around 10 to 15% of adults with epilepsies, often combined with other generalised seizures. They may remit with age or be lifelong.

Syndromic diagnosis is important for treatment strategies and prognosis. Absences may be severe and the only seizure type, as in childhood absence epilepsy. They may predominate in other syndromes or be mild and nonpredominant in syndromes such as juvenile myoclonic epilepsy where myoclonic jerks and generalised tonic clonic seizures are the main concern. Typical absence status epilepticus occurs in about 30% of patients and is more common in certain syndromes, e.g. idiopathic generalised epilepsy with perioral myoclonia or phantom absences.

Typical absence seizures are often easy to diagnose and treat. Valproic acid, ethosuximide and lamotrigine, alone or in combination, are first-line therapy. Valproic acid controls absences in 75% of patients and also GTCS (70%) and myoclonic jerks (75%); however, it may be undesirable for some women. Similarly, lamotrigine may control absences and GTCS in possibly 50 to 60% of patients, but may worsen myoclonic jerks; skin rashes are common. Ethosuximide controls 70% of absences, but it is unsuitable as monotherapy if other generalised seizures coexist. A combination of any of these 3 drugs may be needed for resistant cases. Low dosages of lamotrigine added to valproic acid may have a dramatic beneficial effect. Clonazepam, particularly in absences with myoclonic components, and acetazolamide may be useful adjunctive drugs.

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Acknowledgements

I wish to acknowledge the significant suggestions and contributions of Dr P.N. Patsalos in the initial drafts of this report.

The author declares that he has no conflict of interest in relation to drugs or other matters in this report. In the last 7 years he has not participated in drug-sponsored studies and has not accepted invitations from drug companies to either speak at or attend meetings at their expense. In the early 1990s the author had limited paid presentations (≈20) for Wellcome, Marion Merrel Dow, Sanofi and Ciba-Geigy. Over the same period, Marion Merrel Dow had sponsored a clinical research fellow in the author’s department, Sanofi had sponsored an international meeting and Parke-Davis another international meeting.

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  1. Department of Clinical Neurophysiology and Epilepsies, St Thomas’ Hospital, Lambeth Palace Road, London, SE1 7EH, England

    C. P. Panayiotopoulos

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Panayiotopoulos, C.P. Treatment of Typical Absence Seizures and Related Epileptic Syndromes. Paediatr Drugs 3, 379–403 (2001). https://doi.org/10.2165/00128072-200103050-00006

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