eMedicine Specialties > Neurology > Seizures and Epilepsy

First Seizure in Adulthood, Diagnosis and Treatment: Follow-up

Author: Eissa Ibrahim AlEissa, MBBS, MD, Fellow in EEG and Epilepsy, Tampa General Hospital
Coauthor(s): Selim R Benbadis, MD, Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, University of South Florida School of Medicine, Tampa General Hospital
Contributor Information and Disclosures

Updated: Aug 21, 2009

Follow-up

Further Inpatient Care

  • Many patients who have a seizure recover spontaneously and fully with normal consciousness after a short time interval. Patients with incomplete recovery or a prolonged postictal state may require inpatient hospitalization.7
  • Inpatient management may be necessary if the clinical course is complicated by other medical problems requiring inpatient management.
  • A short hospitalization may be necessary for patients who are at risk of recurrent seizures and have no adequate supervision at home. Patients admitted from an emergency department had a 16.8% risk of an early recurrent seizure during their brief hospitalization.24 This risk of early recurrent seizures was higher than reported in other studies.31,30,14

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • Patients who have had a single epileptic seizure are at increased risk of having a second seizure. They should be informed that they are at increased risk of injury to themselves or others if another seizure occurs. Risk of injury is especially important if patients are driving, operating dangerous machinery, or performing other activities that could put themselves or others at risk. These same concerns also apply to nonepileptic conditions such as syncope that might recur and put the patient or others at risk of injury. The patient should be advised to contact the state agency that regulates driving privileges. This discussion with the patient should be documented in the medical record. Driving regulations vary from state to state. The restrictions sometimes apply to any alteration or loss of consciousness from any etiology.
  • Counseling patients about driving after a first seizure revolves around 2 issues: the diagnosis and the chance of recurrence.
  • Patients with a first epileptic seizure and with risk factors such as remote symptomatic etiology or EEG with epileptiform discharges are at higher risk for a second seizure. Restrictions of hazardous activity should be more emphatic for these patients.

Special Concerns

  • The diagnosis of epilepsy refers to recurrent seizures and cannot be made on the basis of a single episode, even if anticonvulsant treatment is administered. This is especially important because of the serious medical, social, economic, and legal consequences surrounding the diagnosis of epilepsy.
  • The annual cost of misdiagnosis of nonepileptic spells as epileptic seizures is estimated to be between $650 million and $4 billion.42
 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author William J Nowack, MD, to the original writing and development of this article.



More on First Seizure in Adulthood, Diagnosis and Treatment

Overview: First Seizure in Adulthood, Diagnosis and Treatment
Differential Diagnoses & Workup: First Seizure in Adulthood, Diagnosis and Treatment
Treatment & Medication: First Seizure in Adulthood, Diagnosis and Treatment
Follow-up: First Seizure in Adulthood, Diagnosis and Treatment
Multimedia: First Seizure in Adulthood, Diagnosis and Treatment
References
[ CLOSE WINDOW ]

References

  1. Scheepers B, Clough P, Pickles C. The misdiagnosis of epilepsy: findings of a population study. Seizure. Oct 1998;7(5):403-6. [Medline].

  2. Benbadis SR. Differential diagnosis of epilepsy. Continuum Lifelong Learn Neurol. 2007;13:48-70.

  3. [Guideline] Engel J Jr. Report of the ILAE classification core group. Epilepsia. Sep 2006;47(9):1558-68. [Medline].

  4. [Guideline] Jallon P, Hauser A, Roman GC. Guidelines for epidemiologic studies on epilepsy. Epilepsia. 1993;34(4):592-596. [Medline].

  5. [Guideline] Roger J, Dreifuss FE, Martinez-Lage M. Proposal for revised classification of epilepsies and epileptic syndromes. Epilepsia. 1989;30(4):389-399. [Medline].

  6. Pohlmann-Eden B, Beghi E, Camfield C, Camfield P. The first seizure and its management in adults and children. BMJ. Feb 11 2006;332(7537):339-42. [Medline].

  7. Moore-Sledge CM. Evaluation and management of first seizures in adults. Am Fam Physician. Sep 15 1997;56(4):1113-20. [Medline].

  8. Beghi E, Berg AT, Hauser WA. Treatment of Single Seizures. In: Engel J Jr, Pedley TA, eds. Epilepsy: A Comprehensive Textbook. Lippincott-Raven; 1997:1287-94.

  9. Hesdorffer D, Benn E, Cascino G, Hauser W. Is a first acute symptomatic seizure epilepsy? Mortality and risk for recurrent seizure. Epilepsia. 2009;50(5):1102-1108.

  10. van Donselaar CA, Schimsheimer RJ, Geerts AT, Declerck AC. Value of the electroencephalogram in adult patients with untreated idiopathic first seizures. Arch Neurol. Mar 1992;49(3):231-7. [Medline].

  11. Musicco M, Beghi E, Solari A, Viani F. Treatment of first tonic-clonic seizure does not improve the prognosis of epilepsy. First Seizure Trial Group (FIRST Group). Neurology. Oct 1997;49(4):991-8. [Medline].

  12. Hopkins A, Garman A, Clarke C. The first seizure in adult life. Value of clinical features, electroencephalography, and computerised tomographic scanning in prediction of seizure recurrence. Lancet. Apr 2 1988;1(8588):721-6. [Medline].

  13. King MA, Newton MR, Jackson GD, et al. Epileptology of the first-seizure presentation: a clinical, electroencephalographic, and magnetic resonance imaging study of 300 consecutive patients. Lancet. Sep 26 1998;352(9133):1007-11. [Medline].

  14. Annegers JF, Shirts SB, Hauser WA, Kurland LT. Risk of recurrence after an initial unprovoked seizure. Epilepsia. Jan-Feb 1986;27(1):43-50. [Medline].

  15. Bora I, Seckin B, Zarifoglu M, et al. Risk of recurrence after first unprovoked tonic-clonic seizure in adults. J Neurol. Feb 1995;242(3):157-63. [Medline].

  16. Hauser WA, Annegers JF, Kurland LT. Incidence of epilepsy and unprovoked seizures in Rochester, Minnesota: 1935-1984. Epilepsia. May-Jun 1993;34(3):453-68. [Medline].

  17. Sheldon R, Rose S, Ritchie D, Connolly SJ, Koshman ML, Lee MA. Historical criteria that distinguish syncope from seizures. J Am Coll Cardiol. Jul 3 2002;40(1):142-8. [Medline].

  18. Hesdorffer DC, Benn EK, Cascino GD, Hauser WA. Is a first acute symptomatic seizure epilepsy? Mortality and risk for recurrent seizure. Epilepsia. May 2009;50(5):1102-8. [Medline].

  19. Benbadis SR. The differential diagnosis of epilepsy: A critical review. Epilepsy Behav. 2009;15:15-21.

  20. Benbadis SR, Wolgamuth BR, Goren H, Brener S, Fouad-Tarazi F. Value of tongue biting in the diagnosis of seizures. Arch Intern Med. Nov 27 1995;155(21):2346-9. [Medline].

  21. Benbadis SR. Provocative techniques should be used for the diagnosis of psychogenic nonepileptic seizures. Arch Neurol. Dec 2001;58(12):2063-5. [Medline].

  22. Benbadis SR. Errors in EEGs and the misdiagnosis of epilepsy: importance, causes, consequences, and proposed remedies. Epilepsy Behav. 2007;11:257-262.

  23. Zaidi A, Clough P, Cooper P, et al. Misdiagnosis of epilepsy: many seizure-like attacks have a cardiovascular cause. J Am Coll Cardiol. Jul 2000;36(1):181-4. [Medline].

  24. Tardy B, Lafond P, Convers P, et al. Adult first generalized seizure: etiology, biological tests, EEG, CT scan, in an ED. Am J Emerg Med. Jan 1995;13(1):1-5. [Medline].

  25. Chadwick D, Smith D. Epileptology of the first-seizure presentation. Lancet. Dec 5 1998;352(9143):1855; author reply 1856. [Medline].

  26. Simpson CS, Barlow MA, Krahn AD, et al. Recurrent seizure diagnosed by the insertable loop recorder. J Interv Card Electrophysiol. Oct 2000;4(3):475-9. [Medline].

  27. Schreiner A, Pohlmann-Eden B. Value of the early electroencephalogram after a first unprovoked seizure. Clin Electroencephalogr. Jul 2003;34(3):140-4. [Medline].

  28. Benbadis SR., Lin K. Errors in EEG interpretation and misdiagnosis: which EEG patterns are overread?. Eur Neurol. 2008;59:267-271.

  29. Benbadis SR, Tatum WO. Overintepretation of EEGs and misdiagnosis of epilepsy. J Clin Neurophysiol. Feb 2003;20(1):42-4. [Medline].

  30. Musicco M, Beghi E, Bordo B. Randomized clinical trial on the efficacy of antiepileptic drugs in reducing the risk of relapse after a first unprovoked tonic-clonic seizure. First Seizure Trial Group (FIR.S.T. Group). Neurology. Mar 1993;43(3 Pt 1):478-83. [Medline].

  31. Hauser WA, Rich SS, Annegers JF, Anderson VE. Seizure recurrence after a 1st unprovoked seizure: an extended follow-up. Neurology. Aug 1990;40(8):1163-70. [Medline].

  32. Berg AT, Shinnar S. The risk of seizure recurrence following a first unprovoked seizure: a quantitative review. Neurology. Jul 1991;41(7):965-72. [Medline].

  33. Labovitz DL, Hauser WA, Sacco RL. Prevalence and predictors of early seizure and status epilepticus after first stroke. Neurology. Jul 24 2001;57(2):200-6. [Medline].

  34. Martinovic Z, Jovic N. Seizure recurrence after a first generalized tonic-clonic seizure, in children, adolescents and young adults. Seizure. Dec 1997;6(6):461-5. [Medline].

  35. Camfield PR, Camfield CS, Dooley JM, et al. Epilepsy after a first unprovoked seizure in childhood. Neurology. Nov 1985;35(11):1657-60. [Medline].

  36. Chandra B. First seizure in adults: to treat or not to treat. Clin Neurol Neurosurg. 1992;94 Suppl:S61-3. [Medline].

  37. Stein MA, Kanner AM. Management of newly diagnosed epilepsy: a practical guide to monotherapy. Drugs. 2009;69(2):199-222. [Medline].

  38. Heller AJ, Chesterman P, Elwes RD, et al. Phenobarbitone, phenytoin, carbamazepine, or sodium valproate for newly diagnosed adult epilepsy: a randomised comparative monotherapy trial. J Neurol Neurosurg Psychiatry. Jan 1995;58(1):44-50. [Medline].

  39. Marson AG, Al-Kharusi AM, Alwaidh M, Appleton R, Baker GA, Chadwick DW. The SANAD study of effectiveness of carbamazepine, gabapentin, lamotrigine, oxcarbazepine, or topiramate for treatment of partial epilepsy: an unblinded randomised controlled trial. Lancet. Mar 24 2007;369(9566):1000-15. [Medline].

  40. Marson AG, Al-Kharusi AM, Alwaidh M, Appleton R, Baker GA, Chadwick DW. The SANAD study of effectiveness of valproate, lamotrigine, or topiramate for generalised and unclassifiable epilepsy: an unblinded randomised controlled trial. Lancet. Mar 24 2007;369(9566):1016-26. [Medline].

  41. Smith C, Marson AG, Chadwick D, Williamson P. Multiple treatment comparisons in epilepsy monotherapy trials. Trials. November 2007;(8):34.

  42. Nowack WJ. Epilepsy: a costly misdiagnosis. Clinical Electroencephalogr. 1997;28(4):225-228. [Medline].

  43. Davidson DL. What to do with the first fits. Scott Med J. Feb 1999;44(1):6-8. [Medline].

  44. Fisher RS. Imitators of Epilepsy. New York, NY: Demos Publications; 1994:372.

  45. Hart YM, Sander JW, Johnson AL, Shorvon SD. National General Practice Study of Epilepsy: recurrence after a first seizure. Lancet. Nov 24 1990;336(8726):1271-4. [Medline].

  46. Johnson LC, DeBolt WL, Long MT, et al. Diagnostic factors in adult males following initial seizures. A three-year follow-up. Arch Neurol. Sep 1972;27(3):193-7. [Medline].

  47. Liporace JD, Sperling MR. Simple autonomic seizures. In: Engel J Jr, Pedley TA, eds. Epilepsy: A Comprehensive Textbook. Philadelphia, PA: Lippincott-Raven; 1997:549-55.

  48. Morrison AD, McAlpine CH. The management of first seizures in adults in a district general hospital. Scott Med J. Jun 1997;42(3):73-5. [Medline].

  49. Pohlmann-Eden B, Schreiner A. Epileptology of the first-seizure presentation. Lancet. Dec 5 1998;352(9143):1855-6. [Medline].

  50. Sander JW, Hart YM, Johnson AL, Shorvon SD. National General Practice Study of Epilepsy: newly diagnosed epileptic seizures in a general population. Lancet. Nov 24 1990;336(8726):1267-71. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

first seizure in adulthood, first fit, paroxysmal clinical events, epileptic seizure, epilepsy, status epilepticus, idiopathic epilepsy, epilepsy syndromes, cryptogenic seizure, seizure of unknown etiology, symptomatic seizure, stroke, traumatic brain injury, syncope, nonepileptic event, tonic-clonic seizures, syncope, transient ischemic attack, transient global amnesia, migraine, sleep disorder, movement disorder, vertigo, tongue biting, head turning, posturing, urinary incontinence, cyanosis, prodromal deja-vu, head trauma, meningitis, encephalitis, neurodegenerative diseases, brain neoplasm, uremia, hypoglycemia, hyponatremia, hypocalcemia, PNEAs, psychogenic nonepileptic attacks, treatment, diagnosis

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Eissa Ibrahim AlEissa, MBBS, MD, Fellow in EEG and Epilepsy, Tampa General Hospital
Eissa Ibrahim AlEissa, MBBS, MD is a member of the following medical societies: American Academy of Neurology
Disclosure: Nothing to disclose.

Coauthor(s)

Selim R Benbadis, MD, Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, University of South Florida School of Medicine, Tampa General Hospital
Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, and American Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Anthony M Murro, MD, Laboratory Director, Professor, Department of Neurology, Medical College of Georgia
Anthony M Murro, MD is a member of the following medical societies: American Academy of Neurology and American Epilepsy Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Jose E Cavazos, MD, PhD, FAAN, Associate Professor with Tenure, Departments of Neurology, Pharmacology, and Physiology, University of Texas Health Science Center at San Antonio; Co-Director, South Texas Comprehensive Epilepsy Center; Director of the Epilepsy Center, Audie L Murphy Veterans Affairs Medical Center
Jose E Cavazos, MD, PhD, FAAN is a member of the following medical societies: American Academy of Neurology, American Clinical Neurophysiology Society, American Epilepsy Society, and Society for Neuroscience
Disclosure: Nothing to disclose.

CME Editor

Selim R Benbadis, MD, Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, University of South Florida School of Medicine, Tampa General Hospital
Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Selim R Benbadis, MD, Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, University of South Florida School of Medicine, Tampa General Hospital
Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, and American Medical Association
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.