eMedicine Specialties > Neurology > Seizures and Epilepsy

First Seizure in Adulthood, Diagnosis and Treatment: Treatment & Medication

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

Treatment

Medical Care

  • Many patients who have a single seizure do not require anticonvulsant therapy. The physician and patient or family should decide jointly whether to institute anticonvulsant therapy after a single seizure. This decision is based on a discussion of the risk of seizure recurrence, the effectiveness of anticonvulsant treatment, and the adverse medical and socioeconomic effects of anticonvulsant treatment.
  • A first seizure provoked by an acute brain insult is unlikely to recur (3-10%), whereas a first unprovoked seizure has a recurrence risk of 30-50% over the next 2 years. Even among symptomatic seizures, the recurrence rate differs according to the underlying cause. Seizures associated with reversible metabolic or toxic disturbances are associated with a minor risk of subsequent epilepsy (£ 3% based on large case series). Seizures provoked by disorders that cause permanent damage to the brain, such as brain abscess, have a higher risk of recurrence (³ 10%).6
  • Among medically untreated patients in one study, the cumulative 2-year risk of seizure recurrence was 51%.30 Hauser et al found that variability in the reported risks of seizure recurrence may have been due to the following:31
    • Variations in patient populations: Some studies reflect the risk in referral populations; other studies reflect the risk in a more general patient population.
    • Variations in the specificity and sensitivity of case definitions
    • Misclassification of cases: Hauser et al found that 74% of the patient cohort required exclusion because of a previous unprovoked seizure.16
    • Variations in time of ascertainment
    • Biases from retrospective study design
    • Confounding effect of anticonvulsant treatment: Many of the previous studies included patients who received anticonvulsant therapy after their first seizure.
  • Risk factors for recurrent seizures include the following:
    • Age younger than 16 years: Musicco et al found that children younger than 16 years had almost double the risk of recurrent seizures as adolescents and adults aged 16-60 years.30
    • Remote symptomatic seizure:14,31,32 In the case of seizures after a first stroke, Labovitz et al found that lesion location and stroke subtype are strong predictors of early seizure risk, and early seizures are a predictor of recurrent seizures.33
    • Seizures occurring between midnight and 8:59 am12,34,15
    • Prior provoked seizures31
    • Previous febrile seizure6
    • Family history of epilepsy;6  remote symptomatic seizure in a patient whose sibling is affected with epilepsy
    • Status epilepticus or multiple seizures within 24 hours as the initial remote symptomatic seizure31
    • Partial seizures14,32
    • Todd paralysis in patients with a remote symptomatic seizure31
    • History of neurologic deficit from birth such as cerebral palsy or mental retardation14
    • Abnormal examination findings in patients without a remote symptomatic seizure14,35
    • CT scan that shows a brain tumor12
    • EEG that shows epileptiform discharges
      • In patients with a first seizure and no known etiology, van Donselaar obtained a routine EEG in all cases and a second sleep-deprived EEG if the first EEG did not show epileptiform discharges.10 His pooled results showed the following 2-year cumulative risks of seizure recurrence: in patients with epileptiform discharges, 83%; in patients with nonepileptiform abnormalities, 41%; and in patients with normal EEGs, 12%.
      • In 1997, Beghi et al found that epileptiform discharges were associated with a 1.5- to 3-fold increase in the risk of seizure recurrence.8
      • In 1993, Musicco et al found that epileptiform discharges were associated with a 1.7-fold increased seizure recurrence risk.30
      • Berg and Shinnar found that epileptiform discharges were associated with a 2-fold increased seizure recurrence risk.32
      • In 1990, Hauser et al found that generalized spike and wave increased the risk of recurrent seizure in patients with no known etiology.31
      • In 1997, Beghi et al found that an abnormal EEG finding and the presence of an underlying etiology (remote symptomatic) are the most consistent predictors of recurrence.8
  • Immediate anticonvulsant treatment reduces the likelihood of a second seizure by half.30 According to a 1993 report, Chandra found that valproate treatment reduced seizure recurrence rates from 63% to 4.3%.36
  • Immediate anticonvulsant therapy does not affect the long-term prognosis for achieving 1-year or 2-year seizure-free remission and exposes many patients who would never have a recurrent seizure to anticonvulsant side effects.11
  • The general consensus is that anticonvulsant treatment is needed after 2 seizures. The decision to provide anticonvulsant treatment after one seizure should be individualized.
    • Two situations that are often encountered in clinical practice and should be distinguished are a first seizure and new-onset epilepsy with more than one unprovoked seizure. Berg and Shinnar emphasized the need to distinguish between these two entities in clinical studies.32
    • Seizure recurrence risk is substantially higher after 2 or more unprovoked seizures than after just one.31

Medication

The chosen antiepileptic drug should have high efficacy, long term safety, good tolerability, and low interaction potential and should allow a good quality of life, especially because half of all patients never have another seizure without treatment.6 These agents prevent seizure recurrence and terminate clinical and electrical seizure activity.37  

The accepted principle is that one should begin with monotherapy. All newer (second-generation) agents are acceptable choices and are likely just as effective as older agents. A recent American Academy of Neurology (AAN) evidence-based guideline recommended lamotrigine, oxcarbazepine, topiramate, and gabapentin as appropriate for initial monotherapy; however, this did not include newer antiepileptic drugs, such as levetiracetam and pregabalin.

In a 1995 report, phenytoin, carbamazepine, valproate, and phenobarbital were equally effective in treating newly diagnosed epilepsy; phenobarbital had more adverse effects.38 Others agree that barbiturates should be avoided because of neurotoxic and cognitive side effects.6
 
The SANAD study compared carbamazepine, gabapentin, lamotrigine, oxcarbazepine, and topiramate for treatment of partial seizures.39 The study reported that lamotrigine was significantly better in terms of time to treatment failure than the current standard treatment, carbamazepine, and the newer drugs gabapentin and topiramate. For time to 12-month remission from seizures, carbamazepine was not significantly adventageous compared with lamotrigine. Lamotrigine also has the lowest incidence of treatment failure and has better outcome than all drugs except oxcarbazepine.
 
The same SANAD study compared valproate, lamotrigine, or topiramate for generalized and unclassifiable epilepsy seizures.40 The study reported that valproate is the drug of choice and is better tolerated than topiramate.

Another study compared 8 antiepileptic drugs used in 20 randomized trials. In patients with partial seizures, results favor carbamazepine, oxcarbazepine and lamotrigine. For generalized tonic-clonic seizures, results favor valproate and phenytoin.41

Overall the newer antiepileptic drugs appear safer and better tolerated; however, they have not been used for as long or in as many patients as the older drugs. None of the common side effects of the older drugs (eg, gum hyperplasia, neuropathy) have been identified; however, ruling out potential new problems with long-term use of the newer antiepileptic drugs is difficult. Head-to-head studies have demonstrated favorable side effect profiles for gabapentin when compared with carbamazepine, and for oxcarbazepine and lamotrigine when compared with both phenytoin and carbamazepine.

All newer antiepileptic drugs, although "officially" approved as adjunctive therapy, are acceptable options for monotherapy (off-label use).

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
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References

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Further Reading

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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

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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.

 
 
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