Can Seizure Medication Make Rolandic Epilepsy or ESES Worse?

Yes, certain anti-seizure medications—specifically sodium-channel blockers like oxcarbazepine and carbamazepine—have been reported in some cases to worsen the electrical disturbances in the brain associated with Rolandic epilepsy ^[1]. While many children take these medications safely and effectively, there is an uncommon possibility that they can aggravate sleep-time electrical spikes and potentially contribute to a condition called Encephalopathy with Status Epilepticus in Sleep (ESES) or Spike-Wave Activation in Sleep (SWAS) ^[2][1]. Because of this possibility, doctors monitor children starting these medications for any sudden changes in learning, behavior, or seizure types. It is important to remember that most children do not experience this, and any medication changes must be made with medical supervision.

The Paradox: When Treatment Worsens Symptoms

Parents are often alarmed to learn that a medication meant to stop seizures might potentially worsen the condition. In self-limited epilepsy with centrotemporal spikes (SeLECTS, the current medical name for Rolandic epilepsy), seizures typically happen at night or upon waking, though they can occasionally occur during the day.

While medications like oxcarbazepine and carbamazepine are commonly used to control focal seizures, observational experience and select case reports suggest they can sometimes cause a “paradoxical aggravation” ^[3]. This means that rather than calming the brain’s electrical activity, the medication may be associated with an increase in abnormal electrical discharges (spikes) during sleep ^[1][4].

From Rolandic Epilepsy to ESES / SWAS

During non-rapid eye movement (NREM) sleep, the brain normally synchronizes its networks. In children with SeLECTS, sleep-activated spikes can occur. In rare cases, these spikes can become near-continuous during sleep. This EEG pattern is called ESES (Electrical Status Epilepticus in Sleep) or SWAS (Spike-Wave Activation in Sleep) ^[2]. Note that ESES is a pattern seen on an EEG, not a continuous physical convulsion or convulsive status epilepticus.

When near-continuous spikes disrupt sleep, a child might experience cognitive and behavioral regression—a loss of previously acquired skills ^[5]. The exact biological mechanism for why sodium-channel blockers might trigger this in some children is still debated, though some researchers hypothesize these drugs might inadvertently enhance certain excitatory signals in the brain ^[6].

It is essential to understand that causality and frequency are not fully established. Many children take oxcarbazepine or carbamazepine with excellent seizure control and no negative effects ^[7]. The clearest direct evidence of this medication risk comes from case reports where a child rapidly developed cognitive deterioration and ESES shortly after starting the medication, and then improved after the drug was stopped ^[1]. However, progression to SWAS can also happen as part of the natural evolution of the underlying epilepsy, regardless of medication ^[8].

Signs of Worsening to Watch For

Because of this potential risk, evaluating treatment for SeLECTS involves looking beyond visible seizures to monitor your child’s learning and behavior ^[9].

If your child is starting a medication like oxcarbazepine, watch for sudden, persistent, or progressive loss of previously acquired skills. Note that some symptoms can also just be ordinary medication side effects (like sleepiness or dizziness) or signs of typical school stress. However, concerning signs of cognitive or behavioral regression include:

• Academic Decline: A sudden, persistent drop in school performance, or loss of reading or math skills they had already mastered ^[10][5].
• Language Difficulties: Trouble finding the right words, speaking in simpler sentences, or trouble understanding instructions ^[11][12].
• Behavioral Changes: Severe, new restlessness, poor attention span, or irritability ^[10].
• Motor Problems: Sudden, frequent falls or repeatedly dropping objects. While this could be dizziness from medication, it could also be a type of seizure called epileptic negative myoclonus (a brief loss of muscle tone) ^[13][14].
• Changes in Seizures: A noticeable increase in seizure frequency, new types of daytime seizures, or new daytime staring spells ^[15].

What to Do If You Suspect a Problem

If you notice signs of developmental regression or a change in seizures, contact your child’s neurologist to arrange a prompt evaluation ^[16]. Keep a log of your child’s symptoms, sleep patterns, and when medication doses were changed.

When to Seek Emergency Help
Not all changes are emergencies. However, you should call emergency services (like 911) or follow your child’s emergency seizure action plan if your child has:

• A seizure lasting 5 minutes or longer
• Repeated seizures without waking up in between
• Difficulty breathing during or after a seizure
• A serious injury during a seizure

Medical Evaluation
Do not stop or change the dose of the medication on your own. Abruptly stopping seizure medications can be dangerous.

If cognitive regression is suspected, your doctor may order an EEG that captures non-REM sleep ^[17][18]. A standard 20-minute awake EEG might not be enough to detect ESES because the spikes primarily happen during NREM sleep ^[19][18]. While an overnight study is sometimes used, a routine EEG that successfully captures a sufficient amount of sleep can also be informative.

If the sleep EEG shows ESES/SWAS and is accompanied by clinical regression, your pediatric neurologist may carefully taper the suspected medication and discuss alternative treatment options ^[20][1]. There is no single “best” alternative—every medication has its own profile. For instance, levetiracetam can sometimes cause behavioral irritability, valproic acid carries liver and reproductive risks, and clobazam can cause sedation ^[20][16]. Your doctor will individualize the treatment plan based on the EEG results, seizure burden, and your child’s specific needs.