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Do anticonvulsants alter the natural course of epilepsy? Case for early treatment is not established.

The most important question in epilepsy is whether antiepileptic drugs not only reduce susceptibility to seizures in someone with epilepsy but also modify the natural course of the condition. The concept of a process of epileptogenesis is strongly grounded in the large volume of work on the kindling model of epilepsy1 and is supported by some circumstantial clinical evidence. However, I believe that the clinical evidence weighs against early treatment with antiepileptic drugs affecting natural course at a practical level.

Epilepsy is a group of disorders in which seizures occur and not a homogeneous disease entity. The response to antiepileptic drugs may therefore differ. The issue of heterogeneity can be partly addressed by looking at the prognosis for epilepsy syndromes and the likelihood of their being influenced by antiepileptic drugs. One clear cut children's epilepsy syndrome is that of benign rolandic epilepsy, in which focal motor seizures, usually affecting the face, throat, and arm, occur during sleep in children between the ages of 7 and 12. Seizures stop by mid-adolescence,2 and many paediatricians no longer give such children antiepileptic drugs since the outcome seems to be entirely benign whether or not treatment is given.

A rather different picture arises in …