Published: 2022-08-29

Optimizing epilepsy treatment in children, adults and elderly: clinical perspectives

Parthasarthy Satishchandra, Sudhir V. Shah, Pushpendra N. Renjen


Epilepsy is a common neurological condition among all age groups. Its diagnosis depends on clinical history and is supported by investigations like electroencephalograph and magnetic resonance imaging. In children, febrile seizures and juvenile myoclonic seizures are common. In adults and elderly, epilepsy could be new onset or present since childhood. Several antiseizure medications (ASMs) are available for treatment of epilepsy. Each of these drugs has different advantages as well as limitations. Several factors including patient related factors (e. g. age, comorbidities, and gender), seizure characteristics and epilepsy type, and drug related factors (namely, pharmacokinetics, pharmacodynamics, efficacy, side effects, and risk of drug-drug interactions) are considered while selecting drug therapy. There are concerns related to teratogenicity due to pharmacotherapy in females of child-bearing potential. Elderly patients also need special considerations while selecting an appropriate treatment option for epilepsy. Advisory board meetings with a group of expert neurologists were conducted at eight cities across India to gain clinical insights on management of epilepsy in different age groups. Consensus was supported by relevant literature obtained from PubMed and Google scholar using the keywords ‘epilepsy’, ‘diagnosis’, ‘children’, ‘adults’, ‘elderly’, and ‘management’. According to the experts, choice of appropriate ASM is driven by patient- and drug-related factors and seizure characteristics. In India, valproate remains a commonly prescribed agent except in females of childbearing age. Levetiracetam is preferred because of its safety profile whereas clobazam is an effective initial add-on therapy. Newer drugs are largely useful as adjuvants.


Drug therapy, Epilepsy, Optimization, Risk benefit ratio

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Fisher RS, Acevedo C, Zrzimanoglou A, Bogacz A, Cross JH, Elger CE, et al. ILAE official report: a practical clinical definition of epilepsy. Epilepsia. 2014;55:475-82.

Fisher RS, Cross H, D’Souza C, French JA, Haut SR, Higurashi N, et al. Instruction manual for the ILAE 2017 operational classification of seizure types. Epilepsia. 2017;58:531-42.

Thijs RD, Surges R, O’Brien TJ, Sander JW. Epilepsy in adults. Lancet. 2019;393:689-701.

Amudhan S, Gururaj G, Satishchandra P. Epilepsy in India I: Epidemiology and public health. Ann Indian Acad Neurol. 2015;18:263-77.

Sirven JI. Epilepsy: A spectrum disorder. Cold Spring Harb Perspect Med. 2015;5:a022848.

Goldenberg MM. Overview of drugs used for epilepsy and seizures: etiology, diagnosis, and treatment. P T. 2010;35(7):392-415.

Meyer AC, Dua T, Ma J, Saxena S, Birbeck G. Global disparities in the epilepsy treatment gap: a systematic review. Bull World Health Organ. 2010;88:260-6.

Bharucha NE. Epidemiology and treatment gap of epilepsy in India. Ann Indian Acad Neurol. 2012;15:352-53.

Lee SK. Old versus new: Why do we need new antiepileptic drugs? J Epilepsy Res. 2014;4:39-44.

Doyle A, Alick S. Choosing antiepileptic drugs. Pract Neurol. 2018;41-5.

Knupp K, Koh S, Park K. Pediatric epilepsy. Five new things. Neurol Clin Pract. 2012;40-7.

Bashiri FA. Childhood epilepsies: What should a pediatrician know? Neurosciences (Riyadh). 2017;2214-9.

Laino D, Mencaroni E, Esposito S. Management of pediatric febrile seizures. Int J Environ Res Public Health. 2018;15:2232.

Mohammadi M. Febrile seizures: Four steps algorithmic clinical approach. Iran J Pediatr. 2010;20:5-15.

Sadleir LG, Scheffer IE. Febrile seizures. BMJ. 2007;334:307-11.

Lee SH, Byeon JH, Kim GH, Eun B-L, Eun S-H. Epilepsy in children with a history of febrile seizures. Korean J Pediatr. 2015;59:74-9.

Leung AKC, Hon KL, Leung TNH. Febrile seizures: an overview. Drugs Context. 2018;7:212536.

Kenney D, Wirrell E. Patient considerations in the management of focal seizures in children and adolescents. Adolesc Health Med Ther. 2014;5:49-65.

Neubauer BA, Grob S, Hahn A. Epilepsy in childhood and adolescence. Dtsch Arztebl Int. 2008;105:319-28.

Hernandez-Vanegas LE, Jara-Prado A, Ochoa A, Rodriguez NRY, Duron RM, Crail-Melendez D, et al. High-dose versus low-dose valproate for the treatment of juvenile myoclonic epilepsy: Going from low to high. Epilepsy Behav. 2016;61:34-40.

Murthy JM, Rao CM, Meena AK. Clinical observations of juvenile myoclonic epilepsy in 131 patients: a study in South India. Seizure. 1998;7:43-7.

Jayalakshmi SS, Rao BS, Sailaja S. Focal clinical and electroencephalographic features in patients with juvenile myoclonic epilepsy. Acta Neurol Scand. 2010;122;115-23.

Genton P, Thomas P, Kasteleijn-Nolst Trenité DGA, Medina MT, Salas-Puig J. Clinical aspects of juvenile myoclonic epilepsy. Epilepsy Behav. 2013;28:S8-14.

Auvin S. Treatment of myoclonic seizures in patients with juvenile myoclonic epilepsy. Neuropsychiatr Dis Treat. 2007;3:729-34.

Bansal R, Suri V, Chopra S, Aggarwal N, Sikka P, Saha SC, et al. Levetiracetam use during pregnancy in women with epilepsy: Preliminary observations from a tertiary care center in Northern India. Indian J Pharmacol. 2018;50:39-43.

Mbizvo GK, Dixon P, Hutton JL, Marson AG. The adverse effects profile of levetiracetam in epilepsy: a more detailed look. Int J Neurosci. 2013;124:627-34.

Ventola CL. Epilepsy management: Newer agents, unmet needs, and future treatment strategies. P T. 2014;39:776-92.

Posner E. Absence seizures in children. BMJ Clin Evid. 2013;12:0317.

Kessler SK, McGinnis E. A practical guide to treatment of childhood absence epilepsy. Pediatric Drugs. 2019;21:15-24.

Tenney JR, Glauser TA. The current state of absence epilepsy: can we have your attention? Epilepsy Curr. 2013;13:135-40.

Rosati A, De Masi S, Guerrini R. Antiepileptic drug treatment in children with epilepsy. CNS Drugs. 2015;29:847-63.

Minardi C, Minacapelli R, Valastro P, Vasile F, Pitino S, Pavone P, et al. Epilepsy in children: From diagnosis to treatment with focus on emergency. J Clin Med. 2019;8:39.

Lagae L. Cognitive side effects of anti-epileptic drugs: The relevance in childhood epilepsy. Seizure. 2006;15:235-41.

Sweney MT. Updates in the medical management of pediatric epilepsy. Transl Pediatr. 2015;4:258-9.

Kaur S, Garg R, Aggarwal S, Chawla SPS, Pal R. Adult onset seizures: Clinical, etiological, and radiological profile. J Famly Med Prim Care. 2018;7:191-7.

Epilepsy in adults: Treatment with medication. Available at: Accessed on 14 March 2022.

Lawthom C. Valproate and epilepsy: for women as well as men. Pract Neurol. 2018;18:222-3.

Miro J, Aiguabella M, Veciana M, Juvany R, Santurini M, Leiva E, et al. Low-dose sodium valproate in the treatment of idiopathic generalized epilepsies. Acta Neurol Scand. 2014;129:e20-3.

Silberstein SD. Preventive migraine treatment. Continuum (Minneap Minn). 2015;21(4):973-89.

Tomson R, Battino D, Perucca E. Teratogenicity of antiepileptic drugs. Curr Opin Neurol. 2019;32:246-52.

Tomson T, Battino D, Bonizzoni E, Craig J, Lindhout D, Sabers E, et al. Dose-dependent risk of malformations with antiepileptic drugs: an analysis of data from the EURAP epilepsy and pregnancy registry. Lancet Neurol. 2011;10:609-17.

Tomson T, Battino D, Bonizzoni E, Craig J, Lindhout D, Perucca E, et al. Comparative risk of major congenital malformations with eight different antiepileptic drugs: a prospective cohort study of the EURAP registry. Lancet Neurol. 2018;17:530-8.

Werhahn KJ. Epilepsy in the elderly. Dtsch Arztebl Int. 2009;106:135-42.

Shariff EM, AlKhamis FA. New onset epilepsy in the elderly: clinical, radiological and electroencephalographic features and treatment responses. Neurosciences. 2017;22:102-6.

Lee SK. Epilepsy in the elderly: Treatment and consideration of comorbid diseases. J Epilepsy Res. 2019;9:27-35.

Liu S, Yu W, Lu Y. The causes of new-onset epilepsy and seizures in the elderly. Neuropsychiatr Dis Treat. 2016;12:1425-34.

Carbamazepine PI 2009. Available at:,018281s048lbl.pdf. Accessed on 14 March 2022.

Leppik IE, Birnbaum AK. Epilepsy in the elderly. Ann N Y Acad Sci. 2010;1184:208-24.

Gauthier AC, Mattson RH. Clobazam: A safe, efficacious, and newly rediscovered therapeutic for epilepsy. CNS Neurosci Ther. 2015;21:543-8.

Rainesalo S, Makinen J, Raitanen J, Peltola J. Clinical management of elderly patients with epilepsy; the use of lacosamide in a single center setting. Epilepsy Behav. 2017;75:86-9.