Although complete seizure control is achievable in 54% to 82% of patients with primary (idiopathic) generalized epilepsy syndromes, there remains a substantial group with inadequate control. Valproate has been considered the drug of choice but is not always effective and might produce unacceptable adverse effects. Several newer drugs have emerged as potential alternatives to valproate, including lamotrigine, levetiracetam, topiramate, and zonisamide. Sedation and tolerance limit the utility of benzodiazepines. For severely refractory patients, drug combinations, vagal nerve stimulation, or felbamate might be considered. Only a few controlled clinical trials have been conducted for these syndromes; more are needed.