Synopsis
Classify childhood epilepsy by seizure type, age, development and EEG pattern, then choose syndrome-appropriate treatment while managing cognitive, behavioural, reproductive and medicine-specific safety risks.
- Classify the event first as focal, generalised, unknown or unclassified, then integrate age at onset, development, examination, EEG and imaging into an epilepsy syndrome where possible.
- Typical absence causes frequent abrupt seconds-long lapses with immediate recovery and generalised spike-wave; ethosuximide is first-line when absence is the only seizure type.
- Juvenile myoclonic epilepsy causes morning myoclonus with or without absence and tonic-clonic seizures; sleep loss is a common trigger and some focal sodium-channel drugs worsen myoclonus.
- Self-limited epilepsy with centrotemporal spikes produces brief nocturnal facial or oropharyngeal focal seizures in otherwise typical school-aged children, but language and learning still deserve assessment.
- Infantile spasms are a developmental emergency: arrange urgent sleep EEG and a specialist pathway; NICE recommends vigabatrin with high-dose oral prednisolone for most, and vigabatrin alone first-line with tuberous sclerosis.
- For focal seizures NICE generally offers lamotrigine or levetiracetam first-line monotherapy, with selection based on age, comorbidity, reproductive safety, interactions and family preference.
- Do not infer treatment from one EEG label; review actual seizure types, because carbamazepine, oxcarbazepine and phenytoin can aggravate absence or myoclonic seizures.
- Start low and titrate, change one drug at a time where safe, check adherence and sleep before declaring resistance, and use a seizure diary with functional outcomes.
- Drug-resistant epilepsy means failure of two appropriately chosen, tolerated regimens to achieve sustained seizure freedom and should trigger tertiary review for surgery, diet or device options.
- Every review should cover rescue plan, school, swimming and bathing, driving when age-relevant, contraception and pregnancy, bone health, mood, cognition and SUDEP proportionately.
Key red flags
Developmental plateau or regression, new movement abnormality or loss of previously acquired language suggests an epileptic encephalopathy or progressive neurological disorder.
Infantile spasms present as brief flexor or extensor clusters, often after waking, and require urgent EEG and specialist treatment to protect development.
Myoclonic jerks after waking with generalised tonic-clonic seizures suggest juvenile myoclonic epilepsy; sodium-channel medicines can aggravate some generalised seizure types.
New focal seizures, persistent focal deficit, raised intracranial-pressure features or a changing examination requires structural imaging and urgent review.
Mood change, suicidality, severe rash, bruising, jaundice, pancreatitis symptoms or marked sedation may represent serious antiseizure-medicine toxicity.
Sodium valproate initiation and continuation require current MHRA safeguards, specialist documentation and pregnancy-prevention measures where applicable.
Investigation priorities
Define seizure types, triggers, developmental trajectory and syndrome before treatment selection.
Management branches
Recurrent unprovoked events or high recurrence risk establishes epilepsy.
- Describe onset, awareness, motor pattern, duration, recovery, age and developmental context.
- Use EEG, MRI and genetic testing only to answer syndrome-specific questions.
- Record uncertainty explicitly and avoid a medicine likely to worsen plausible seizure types.