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Electroencephalograms are widely used to detect interictal epileptiform discharges (IEDs) in patients with a known history of seizures. However, previous studies have not found a consistent association between the presence or frequency of IEDs and clinical epilepsy severity, possibly because of differences in subject characteristics and recording techniques. We sought to investigate this relationship in a population and setting reflective of the most common clinical usage. We analyzed electroencephalograms and clinical records of all consenting patients with a history of at least two presumed focal-onset seizures who presented for routine electroencephalograms recording over 1-year time in an academic neurophysiology laboratory (n = 129). Despite adequate statistical power, we did not find an association between the presence or absence of IEDs or IED frequency and the most recently determined seizure frequency (median, 4 per year). A higher IED incidence was seen in subjects with longer epilepsy duration (P = 0.04). Neither IED incidence nor frequency (median, 10.0 per hour) correlated with age or antiepileptic drug use. Our results differ from those of some previous studies, most of which focused on more narrow subject populations, suggesting that the patient's clinical circumstances must be taken into account before assuming the utility of IEDs on routine electroencephalography in predicting epilepsy severity.