Juvenile myoclonic epilepsy (JME) is a common form of epilepsy that usually is easily controlled by treatment with Depakote (valproate) alone. The syndrome usually requires lifelong treatment but with the right choice of medications, people who have JME can live without seizures and without bothersome medication side effects. The usual effective dose for JME is from 500 to 1000 mg of Depakote per day.

Pitfalls for young adults

Because the seizures generally occur during sleep or within an hour or two of waking up, the Depakote can be given as a single nighttime dose. Teens and young adults, however, often forget to take this dose after being out late at night, or they find themselves away from home without their medication when the time comes. Here are a few tips:

• Keep a dose in your wallet or purse at all times.
• If you expect to be out late, take the dose before you leave home—taking it early is better than not taking it at all.
• Taking a nap before a late night may help to ward off the effects of sleep deprivation, which may bring on seizures, especially when combined with alcohol.

Other problems with Depakote

Most people tolerate this dosage of Depakote quite well, but some suffer from intolerable side effects:

• tremor
• weight gain
• nausea or abdominal discomfort
• hair loss
• irregular menstrual periods

For these patients, JME may be effectively controlled with other seizure medicines without causing unacceptable side effects. The choice of medication is very important, however, because several medicines used to prevent the seizures of JME can actually make them more frequent or intense.

What can I use instead of Depakote?

Lamictal: The next medication chosen to treat JME is frequently Lamictal (lamotrigine). It can be used either in combination with Depakote or by itself and is often effective for myoclonus, absences, and tonic-clonic seizures.

There has been no randomized, controlled trial to compare the effectiveness of Lamictal with Depakote, but doctors who see many patients with JME generally report that Lamictal is not as helpful for the tonic-clonic seizures as Depakote. In fact, it has not been specifically approved by the U.S. Food and Drug Administration (FDA) for the treatment of JME because the necessary types of studies have not been performed.

When Lamictal is used alone, the usual successful dose ranges from 100 to 300 mg per day. Unfortunately, it often takes 2 or more months to reach this dosage because the risk of serious rash is higher with rapid introduction. Some patients require higher doses to achieve control of their seizures, or lower doses to avoid side effects. Worsening of myoclonic jerks has been reported in some patients taking only Lamictal. If this happens, the Lamictal should be stopped or taken in combination with Depakote.

Side effects reported with Lamictal include mild anxiety, mild transient rash, and dizziness. (Life-threatening rashes have occurred, but are very uncommon.) Lamictal has been reported to be safer to use in pregnancy than many other medicines and it is now viewed as a useful alternative in the management of JME.

Topamax: Topamax (topiramate) is another seizure medicine sometimes suggested for the treatment of JME. It has broad activity against the various seizure types of JME and has been reported (in a few instances) to be effective when used alone. The recommended daily dose may be as high as 400 mg per day in two divided doses.

Even at lower dosages, however, it has been reported to cause fatigue, sedation, speech difficulties, and significant cognitive slowing. These side effects can be minimized or resolved by starting the medication slowly and not increasing it once seizures are controlled. Other side effects reported are weight loss and a minor risk of kidney stones.

Frisium: Frisium (clobazam) has met with some success in difficult-to-treat JME patients, but it is not approved in the United States. It has been used in combination with other seizure medicines or as a "bridging" medication while Lamictal is slowly introduced.

Felbatol: Felbatol (felbamate) also has been reported to be effective in JME, but it presents a relatively high risk of lethal side effects. As a result, it is prescribed only for patients whose seizures do not respond to safer medications.

Diamox (acetazolamide), Mysoline (primidone), Zarontin (ethosuximide), and Celontin (methsuximide) have also been successfully used as alternative treatments for JME.

Do some medicines make JME worse?

The seizure medicine most likely to aggravate seizures in JME is Tegretol or Carbatrol (carbamazepine). These medications may increase myoclonic jerks. Patients with JME should avoid Tegretol and Carbatrol, or should use them only in very carefully selected situations with proper warning and close monitoring.

Trileptal (oxcarbazepine), which is closely related to carbamazepine, also is not a good choice for JME.

Dilantin and Phenytek (phenytoin) have been found to show little efficacy and may even aggravate the symptoms of JME. Sabril (vigabatrin), one of the newer seizure medicines (not approved in the United States), also appears to aggravate JME.