Background: Pediatric occipital epileptiform discharges (OEDS) occur in various clinical settings, including benign and symptomatic epilepsies. The study objective is to determine electro-clinical predictors for aetiology and prognosis in children with OEDs. Methods: 205 patients with OEDs were classified into seizure groups: symptomatic (n=98), idiopathic focal (IF) (n=57), idiopathic generalized (IG) (n=18), no-seizures (n=27) and febrile seizures (n=5). Results: The median age of seizure onset was 3 years (range: 0-19). There was more EEG background slowing (P<0.05) in the symptomatic; photosensitivity (P<0.0001) and GSW (P<0.0001) in IG; and presence of consistent EEG spike dipole in IF group. The symptomatic had more DD (P< 0.0001), autism (P <0.019), and school difficulties (P<0.001) than the IF and IG groups, but not different from the no-seizure group. Conclusions: OEDs with consistent dipole spike is predictive of IF epilepsy. In contrast to frontal and temporal lobe epilepsy, only 30% with symptomatic epilepsy had occipital-predominant neuro-imaging abnormalities. Notably, neuro-psychiatric co-morbidities were similar between the symptomatic and no-seizure group.