Blog #58: Questions in the Treatment of a First Seizure

            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.