Absence Seizures: How to Treat What You Can't See

Jon P. Wietholter, PharmD, BCPS; Jonathan M. Kline, PharmD, CACP, BCPS, CDE

US Pharmacist

Abstract and Introduction

Introduction

First described in the early 1700s, absence seizures have been referred to over the years as petits accès, petit mal, epilepsia minor, and pyknolepsy.^[1] Typically thought of as a type of childhood seizure disorder, absence seizures also may present in older populations or as a component of multiple other epileptic disorders.

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Cite this: Absence Seizures: How to Treat What You Can't See - Medscape - Mar 01, 2011.

Table 1. Major Epilepsy Syndromes of Typical Absence Seizures
Childhood Absence Epilepsy
Age of onset 4–10 y (peak 6–7 y), with rare presentations earlier or later; strong genetic predisposition; up to 70% of pts are girls; absences more frequent and severe; myoclonia absent or mild; 1–2 3-Hz spikes on EEG
Juvenile Absence Epilepsy
Age of onset >10 y (peak 12–13 y), with occasional younger outliers; absences less frequent; most pts develop GTCS; up to 1/3 of pts have myoclonic jerks; polyspikes more common on EEG
Juvenile Myoclonic Epilepsy
Age of onset 8–24 y (peak 12–18 y); absence seizures occur in 1/3 of pts; milder absences; myoclonic jerks more severe, often occur on awakening (rare in absence); most pts develop GTCS

EEG: electroencephalogram; GTCS: generalized tonic-clonic seizures; pt: patient.
Source: References 1, 3, 5.

Table 2. Comparison of Typical Absence Versus Complex Partial Seizures
Symptom/EEG Finding	Typical Absence	Complex Partial
General duration	4–20 sec	>30 sec
Frequency	Multiple times daily	Variable
Hyperventilation reproduction	Typical	Rare
3-Hz spike	Diagnostic	Exclusionary
Normal EEG w/o treatment	Rare	Common

EEG: electroencephalogram; sec: second; w/o: without.
Source: Reference 3.

Table 3. Dosing Recommendations for 1st-Line Agents to Treat Absence Seizures
Agent	Adult	Pediatric	Therapeutic Range
Ethosuximide	Initially 500 mg/day; adjust by 250-mg increments every 4–7 days; usual maintenance dose 20–30 mg/kg/day; max dose 1.5 g/day	>6 y: dose as adults; initially 250 mg/day; adjust by 250-mg increments every 4–7 days; usual maintenance dose 20 mg/kg/day; max dose 1.5 g/day	40–100 mcg/mL
Lamotrigine	Initially 25 mg/day for 2 wk; titrate upward over 4–6 wk; usual maintenance dose 225–375 mg/day in 2 divided doses over 4–6 wk; usual maintenance dose 4.5–7.5 mg/kg/day in 2 divided doses; max dose 300 mg/day	>12 y: dose as adults 2–12 y: initially 0.3 mg/kg/day in 1–2 divided doses for 2 wk; titrate upward	N/A
Valproic acid	Initially 15 mg/kg/day in 2–3 doses; increase by 5–10 mg/kg/day at 1-wk intervals; max dose 60 mg/kg/day in 2–3 divided doses	<10 y: not indicated ≥10 y: initially 15 mg/kg/day in 2–3 divided doses; increase by 5–10 mg/kg/day at 1-wk intervals; max dose 60 mg/kg/day in 2–3 divided doses	50–100 mcg/mL

max: maximum; N/A: not applicable.
Source: References 12, 13.

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