Table 2.

Advantages, disadvantages and side effects of suggested antiepileptic drugs for nodding syndrome

Antiepileptic	Oral Dosing	Advantage	Disadvantage	Main side effects
Phenobarbitone	Usual dose in children 3–5mg/kg/day Adolescents >12 yrs: 1–3 mg/kg/day in 1–2 divided doses.	Cheap and easily available even in rural areas Anecdotal reports of some success with tonic clonic seizures.	Central nervous system effects and behaviour difficulties in children There may be no beneficial effect on head nodding.	Skin rash. Drowsiness, lethargy, unsteadiness, unpaired memory or cognition. Behaviour difficulties
Phenytoin	May require a loading dose Usual dose 4–8 mg/kg/day; max.– Daily dose: 300mg/day.	Cheap and easily available even in rural areas	A wide range of side effects. There may be no benefit with seizures in nodding syndrome.	Skin rash. Nausea, vomiting, constipation, drowsiness, insomnia, nervousness, tremor, pins and needles, dizziness, headache, anorexia, gum problems, acne, excess hair growth, and coarse facial features
Carbamazepine	Usual dose 10–20mg/kg/day Start at 5 mg/kg/day Dinded 2 or 3 times daily Increase dose every week until optimal response is achieved; maximum recommended dose: 35 mg/kg/day. Beyond 12 years refer to adult dosing	Available in district and regional hospitals in the affected areas. Also a mood stabiliser. Not recommended	Risk of precipitating myoclonic seizures	Skin rash. Dry mouth, nausea, vomiting, fluid retention, unsteadiness, dizziness, drowsiness, fatigue, and headache, low sodium in the blood blood disorders, dermatitis, and hives.
Sodium valpoate	Start with 10mg/kg/day in two divided doses Increase by 5–10mg/kg/day weekly doses in 2–3 doses until therapeutic levels are achieved or up to 40mg/kg/day.	Suggested first line anti epileptic drug Broad spectrum AED Mood stabilizer	Costly. Carries a higher risk than other AEDs of causing fetal malformations if taken during pregnancy. Pre-conceptual counselling in young girls is time consuming	Hair loss, nausea, stomach upset, diarrhoea, and weight gain and reduced platelets in the blood. Polycystic ovaries and menstrual problems.
Lamotrigine	Monotherapy in children <12 years Start with 0.3mg/kg/day and increase doses eyery 1–2 weeks. Titrate the dose up very slowly. Usual maintenance dose 4.5–7.5mg/kg/day Children> 12 years Weeks 1–2–25 mg/day Week 3–4 25mg twice daily. Increase by 50mg/day weekly doses	Broad spectrum Alternative to sodium valpoate Mood stabilizer	Costly. Not readily available in affected areas May cause severe skin rash and reactions Has to be introduced and titrated upwards very slowly	Severer skin rash and hypersensitivity. Nausea, vomiting, diarrhoea, dry mouth, aggression, agitation, headache, drowsiness, dizziness, tremor, difficulty sleeping, unsteadiness, back pain, joint pain, eye movements, double vision, and blurred vision
Levetiracetam	Initial dose: 20 mg/kg/day in two divided doses; Increase dosage every 2 weeks by 20 mg/kg/day in two divided doses with seizure control up to 60 mg/kg/day in two divided doses.	Alternative to sodium valpoate	Costly Not readily available in affected areas	Anorexia, weight changes, abdominal pain, nausea, vomiting, diarrhoea, drowsiness, unsteadiness, Dizziness, headache, tremor, amnesia, aggression, agitation, depression, anxiety, and double or blurred vision.
Clonazepam	Initial dose: 0.01–0.03 mg/kg/day; Increase bv no more than a total 0.5 mg every third day until seizure control or adverse effects. Usual maintenance dose: 0.1–0.2 mg/kg/day.	May be used as add on therapy with sodium valproate if poor seizure control. Short term Clobazam also suggested.	Costly Not readily available	Drowsiness, lethargy, unsteadiness, impaired memory or cognition. Tolerance