Epilepsy with Myoclonic Absences After Second-Line Antiseizure Medications Have Failed

Clinical Scenario

This protocol addresses epilepsy with myoclonic absences (EMA) that has not responded to second-line antiseizure treatment — a drug-resistant presentation in which further escalation is required to achieve adequate seizure control.

Previous Line — Insufficient Response

Second-line antiseizure medications — including levetiracetam, acetazolamide, zonisamide, topiramate, and lacosamide — were trialled but failed to achieve control of myoclonic absence seizures. This protocol represents the next management step after that failure.

Next-Line Management Approach

For drug-resistant EMA, management involves adjunctive strategies — spanning certain antiseizure medication combinations as well as non-pharmacological interventions. The sequencing, specific agents, and criteria for each option are set out in the full protocol.

The clinical target is seizure freedom, or at least a 50% reduction in seizure frequency.

Instant Access to Structured Evidence-Based Regimens

References

The management of EMA include antiseizure medications (ASMs), vagus nerve stimulation, ketogenic diet and surgical treatment.
Ito et al. reported a child with drug-resistant EMA combined with tonic–clonic seizures achieving complete seizure freedom following the addition of low-dose phenobarbital to a regimen of valproate and ethosuximide.
Supporting these findings, a retrospective study of three children with EMA refractory to conventional ASMs demonstrated that adjunctive rufinamide (RUF) led to seizure freedom in two patients and a 50% seizure reduction in the third, indicating that the addition of RUF had a promising effect.

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