A 16-year-old boy describes jerky movements of both arms within an hour of waking, occurring almost every morning for a year, with two generalised tonic-clonic seizures on sleep deprivation. Neurological examination is normal. Which drug is the best initial choice?

• A Ethosuximide
• B Phenytoin
• C Carbamazepine
• D Valproate ✓

Explanation

Early-morning bilateral myoclonic jerks with infrequent generalised tonic-clonic seizures in an adolescent with a normal examination is juvenile myoclonic epilepsy, a genetic generalised epilepsy that responds well to valproate, though levetiracetam or lamotrigine are preferred in young women for teratogenic reasons. Phenytoin and carbamazepine can aggravate myoclonus. Ethosuximide treats absence seizures but has no efficacy against tonic-clonic seizures of JME.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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