Fear and uncertainty
plague patients and those who are close to them after a first seizure. Will it
happen again? What is to be done? It is here that the art of medicine connects
with the science of medicine in dealing with this unknown.
The first thing I did
when I evaluated a patient was to determine whether the clinical history
suggested prior unrecognized seizure phenomena. Clues would be “fainting” spells
or “panic” spells or losing concentration and loss of mental contact with the
environment or hallucinating bad smells and tastes in their past. These
symptoms can accompany complex partial seizure or other forms of epilepsy. If
the neurological examination and various screening laboratory tests, EEG and
brain scans revealed no risk factors for further seizures, I explained that the
possibility of another seizure cannot be precisely predicted. But, the risk of experiencing
more seizures is greatest during the next two years (21%-45%).1 The
decision by the physician in collaboration with the patient to initiate an
antiepileptic drug (AED) is influenced by many variables: occupation, driving,
social considerations, endangering infants in the patient’s care, whether serious
harm or injury was caused by this first seizure, potential side effects of the
AED, etc. Additionally, AEDs are not always as effective as we desire. They
fully control seizures in only 50% of people with epilepsy—there
is no guarantee: it’s a matter
of trial and error. If these above tests suggested abnormalities that increase epilepsy
risk and that another seizure was likely (i.e., abnormal EEG and/or brain scan
and prior incidents suspicious for seizure/blank outs), I would urge initiating
an AED after a first seizure, especially the convulsive type, rather than “wait
and see.”
Once an AED is
started, it is recommended to take it for two years. If no identifiable seizure
occurs during that time―and the patient is anxious to stop the AED—I would order another EEG to screen for
epileptiform abnormalities. If normal, then taper off the medicine over a few
weeks. However, it is very common in people with epilepsy for EEGs to be normal―epileptiform abnormalities are not always
present. So, the question becomes if the patient was seizure-free during those
two years was it because the AED was effective or because another seizure would
not have occurred anyway?
Studies have shown
that immediate treatment will reduce seizure risk during those two years but
treatment will not necessarily improve the long-term prognosis for seizure
remission.2 If it’s decided to wait and see if a second seizure
occurs before AEDs are prescribed, starting them after a recurrent seizure will
not adversely affect long-term seizure control prognosis.
With the above
considerations in mind, I conclude that watchful-waiting or initiating an AED
immediately after the first seizure are both reasonable choices.
1. Krumholz
A, Wiebe S, Gronseth GS, et al. Evidence-based guideline: Management of an
unprovoked first seizure in adults. Neurology 2015; 84:1705-1712.
2. First
Seizure Trial Group. Randomized clinical trial on the efficacy of antiepileptic
drugs in reducing the risk of relapse after a first unprovoked tonic-clonic
seizure. Neurology 1993; 43: 478-483.
Lance Fogan, M.D. is Clinical Professor of Neurology at the David Geffen School of Medicine at UCLA. “DINGS” is his first novel. It is a mother’s dramatic story that teaches epilepsy, now available in eBook,
audiobook and soft cover editions.
