Ideal situation: Valproate is commonly preferred as the drug of choice for patients with primary generalized epilepsies that do, or can, manifest with multiple seizure types, because it is effective against generalized tonic-clonic seizures, absences, and myoclonic jerks. Other wide-spectrum antiepileptic drugs that can be used to control all seizure types with a single medication include lamotrigine, levetiracetam, zon-isamide, and topiramate. When these drugs fail, polytherapy is necessary for patients who have generalized tonic-clonic seizures and either absences or myoclonic jerks. Absences can be treated with ethosuximide, and myoclonic jerks with clonazepam and, rarely, primidone. Care must be taken when combining medications to avoid pharmacoki-netic and pharmacodynamic interactions that increase the likelihood of adverse events.
Contingency situation: Even while treating IGEs, PB could have an important role as the alternative drug for treatment of different seizures associated with IGEs in developing countries, since this may be the only available AED. Additionally, while CBZ is well known to worsen myoclonic jerks, the use of PHT as a first-line AED in IGEs (as in partial epilepsies) is associated with problems of its adverse effects. Further, both CBZ and PHT are not effective against absence seizures.
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