What is the alternative to Valtoco spray?

October 9, 2025 •

4 min read

With approximately 3.4 million Americans affected by epilepsy, many rely on immediate-use rescue medications like Valtoco for managing seizure clusters. However, patients and caregivers often seek information on alternative options to Valtoco spray due to differing age approvals, administration routes, or side effects. This guide explores other FDA-approved and off-label treatments for acute repetitive seizures.

Quick Summary

Several alternatives exist for treating seizure clusters, including the nasal spray Nayzilam, rectal gel Diastat, and off-label oral benzodiazepines. For long-term management, some patients may consider vagus nerve stimulation (VNS). Each option has distinct differences in administration, age approval, and side effect profiles.

Key Points

Nayzilam Nasal Spray: This midazolam nasal spray is an FDA-approved alternative to Valtoco for treating seizure clusters in patients aged 12 and older.
Diastat Rectal Gel: Rectal diazepam (Diastat) was the original FDA-approved rescue medication for seizure clusters and is effective, though it is less socially accepted due to the administration method.
Oral Benzodiazepines: Off-label oral formulations, such as clonazepam ODT or lorazepam Intensol solution, offer alternatives for some patients, particularly for preventative use in certain scenarios.
Vagus Nerve Stimulation (VNS): This is a long-term, non-pharmacological treatment option that involves a surgically implanted device to reduce overall seizure frequency, but is not an acute rescue therapy.
Age and Administration Method: Considerations like a patient's age, preference for administration (nasal, rectal, oral), and specific seizure profile are crucial when choosing an alternative.
Medical Consultation is Key: All alternatives should be discussed with a healthcare provider to ensure a safe and personalized treatment plan, taking into account potential side effects and interactions.

Primary Intranasal Alternative: Nayzilam

Nayzilam (midazolam) nasal spray is another FDA-approved benzodiazepine rescue medication used for the acute treatment of intermittent, stereotypic episodes of frequent seizures, also known as seizure clusters. Like Valtoco (diazepam), Nayzilam works by enhancing the effects of gamma-aminobutyric acid (GABA), an inhibitory neurotransmitter in the brain that helps calm excessive nerve activity. Nayzilam is approved for use in patients aged 12 and older.

Key Differences from Valtoco

While both are convenient nasal sprays, Nayzilam and Valtoco have several differences. Nayzilam is administered via a single spray into one nostril. If the seizure activity persists after a certain period, a second dose may be administered in the opposite nostril. Valtoco's dosage is based on factors determined by a healthcare professional and can be administered with a second dose potentially administered after a period of time. Another major distinction is their FDA age approval; Nayzilam is approved for patients 12 and older, while Valtoco can be used in patients as young as 2 years old, making Valtoco an option for a broader pediatric age range. In clinical trials, Nayzilam demonstrated an effective reduction of seizure clusters, with common side effects being nasal discomfort and somnolence, similar to those reported with Valtoco.

Established Alternatives: Non-Intranasal Rescue Medications

For decades before the advent of nasal sprays, rectal and oral medications were the standard rescue options for treating seizure clusters. These options remain relevant today, especially for patients with specific needs.

Rectal Diazepam (Diastat)

Rectal diazepam gel, commercially known as Diastat, was the only FDA-approved rescue therapy for acute repetitive seizures for over two decades. It is approved for use in patients aged 2 and older. Diastat is highly effective but faces social acceptability challenges, particularly in public settings like schools, due to its method of administration. However, some caregivers may prefer it for very young children or in private settings. A key advantage is its long history of use, providing extensive data on its efficacy and safety profile.

Oral Benzodiazepine Formulations

Various off-label benzodiazepine formulations are sometimes used as rescue medications, though they do not offer the rapid absorption of intranasal or rectal delivery.

Clonazepam Oral Dissolving Tablets (ODT): This inexpensive wafer formulation dissolves rapidly in saliva, making it a viable option for some patients, particularly for preventing seizures in predictable low-frequency scenarios.
Lorazepam Intensol Solution: This concentrated oral solution can be administered sublingually (under the tongue) for rapid absorption, though it requires refrigeration, which can be an inconvenience.

Alternative Therapeutic Approach: Vagus Nerve Stimulation

For individuals with epilepsy that is resistant to multiple medications, Vagus Nerve Stimulation (VNS) offers a non-pharmacological alternative. VNS involves implanting a small device, similar to a pacemaker, under the skin of the chest. A thin wire is threaded to the left vagus nerve in the neck, and the device sends regular electrical signals to the brain to help normalize electrical activity and reduce seizure frequency. VNS is not a rescue treatment for an active seizure cluster, but a long-term therapy that can reduce the overall occurrence and severity of seizures. It is often used in conjunction with anti-seizure medications and may help improve seizure control over time.

Benefits of VNS

Can reduce seizure frequency and severity over the long term.
May lead to improvements in mood and alertness.
An external magnet can be used by the patient or caregiver to deliver an extra burst of stimulation during a seizure, potentially shortening its duration.

Comparison of Seizure Cluster Rescue Therapies


Feature	Valtoco (Diazepam Nasal Spray)	Nayzilam (Midazolam Nasal Spray)	Diastat (Diazepam Rectal Gel)	Oral Benzodiazepines (e.g., Clonazepam ODT)
Active Ingredient	Diazepam	Midazolam	Diazepam	Clonazepam, Lorazepam, etc.
Route of Administration	Nasal Spray	Nasal Spray	Rectal Gel	Oral/Sublingual
FDA Age Approval	2 years and older	12 years and older	2 years and older	Varies; off-label for rescue use
Onset of Action	Typically within 4 minutes	Within 10 minutes	Rapid absorption, less variable than rectal gel	Highly variable, depends on formulation and absorption
Social Acceptability	High, discreet administration	High, discreet administration	Poor, less socially accepted	High, discreet administration
Common Side Effects	Drowsiness, nasal discomfort, headache	Drowsiness, nasal discomfort, throat irritation, headache	Somnolence, sedation	Drowsiness, confusion, dizziness

Important Considerations for Choosing an Alternative

When evaluating alternatives to Valtoco, several factors should be considered in consultation with a healthcare provider. The choice depends on a patient's age, seizure type, frequency, and personal preferences regarding the method of administration. For instance, while a nasal spray may be more socially acceptable than rectal gel, a patient's nasal issues or age limitations might make another option more suitable. Similarly, while a non-invasive therapy like VNS offers a long-term solution, it's not a substitute for having a readily available rescue medication for acute episodes. Discussing the pros and cons of each option, including potential side effects and interactions with other medications, is critical for creating a safe and effective seizure action plan.

Conclusion

While Valtoco nasal spray provides a convenient and effective option for managing seizure clusters, several alternatives exist to meet different patient needs. Nayzilam offers a similar intranasal delivery method for older children and adults, while Diastat provides a reliable rectal option, particularly for younger children. For those seeking long-term control rather than just rescue treatment, Vagus Nerve Stimulation may be considered. When evaluating what is the alternative to Valtoco spray, consulting a neurologist is the most crucial step. A personalized discussion can help determine the most appropriate rescue and management strategy to effectively control seizures and improve the quality of life for individuals with epilepsy.

Visit the Epilepsy Foundation for more information on seizure rescue therapies.

Frequently Asked Questions

Nayzilam is a viable alternative, but it is not a direct substitute. While both are nasal benzodiazepine rescue medications for seizure clusters, they have different active ingredients, age approvals (Nayzilam 12+, Valtoco 2+), and dosing schedules. Your healthcare provider will determine which is most appropriate for you.

The main differences include the active ingredients (Valtoco uses diazepam, Nayzilam uses midazolam), the approved age ranges (Valtoco for ages 2+, Nayzilam for ages 12+), and the specific dosing instructions. Both have a similar mechanism of action by enhancing GABA activity to stop seizures.

Diastat rectal gel is an effective alternative to Valtoco and is FDA-approved for patients aged 2 and older. While its rectal administration is less convenient and socially acceptable for some, it provides a well-established and reliable option for acute repetitive seizures.

Yes, aside from nasal sprays and rectal gels, some physicians may use off-label oral or sublingual benzodiazepine formulations for rescue therapy. Clonazepam oral dissolving tablets (ODT) and lorazepam concentrated solution are examples, though they may have different absorption profiles.

No, Vagus Nerve Stimulation (VNS) is a long-term treatment designed to reduce overall seizure frequency, not an acute rescue therapy for an ongoing seizure cluster. It is often considered for patients whose seizures are not well-controlled with medication and is used in conjunction with other therapies.

You should discuss several factors with your doctor, including the patient's age, frequency and type of seizure clusters, administration preference (nasal vs. rectal), potential side effects, and cost. A personalized approach is crucial for effective seizure management.

No, rescue medications like Valtoco are for short-term, acute treatment of seizure clusters and do not replace your daily maintenance anti-seizure medication. You should continue taking your daily medication as prescribed while using a rescue medication only as needed.