Approach Considerations
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.
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. [30]
Inpatient management may be necessary if the clinical course is complicated by other medical problems requiring inpatient management. A short hospitalization may also 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. [36] This risk of early recurrent seizures was higher than reported in other studies. [10, 9, 11]
Guidelines
In 2015,the American Academy of Neurology (AAN) and the American Epilepsy Society (AES) released a new guideline on the prognosis and treatment of first unprovoked seizures. [42, 43]
According to the guideline, immediate antiepileptic drug (AED) therapy, as compared with delay of treatment pending a second seizure, is likely to reduce recurrence risk within the first 2 years but may not improve quality of life. Clinicians’ recommendations whether to initiate immediate AED treatment after a first seizure should be based on individualized assessments that weigh the risk of recurrence against the AEs of AED therapy and that consider educated patient preferences. Patients should be advised that risk of AED adverse events (AEs) may range from 7-31% and that these AEs are likely predominantly mild and reversible. [42, 43]
Anticonvulsant Therapy
Immediate anticonvulsant treatment reduces the likelihood of a second seizure by half. [9] According to a report by Chandra, valproate treatment reduced seizure recurrence rates from 63% to 4.3%. [44] However, immediate anticonvulsant therapy does not affect the long-term prognosis for achieving 1- or 2-year seizure-free remission and exposes many patients who would never have a recurrent seizure to anticonvulsant side effects. [24]
The general consensus is that anticonvulsant treatment is needed after 2 seizures. The decision to provide anticonvulsant treatment after 1 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 1 unprovoked seizure. Berg and Shinnar emphasized the need to distinguish between these 2 entities in clinical studies. [12]
Seizure recurrence risk is substantially higher after 2 or more unprovoked seizures than after just 1. [11]
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An electroencephalogram (EEG) recording of a temporal lobe seizure. The ictal EEG pattern is shown in the rectangular areas.
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An electroencephalogram (EEG) recording from a patient with primary generalized epilepsy. A burst of bilateral spike and wave discharge is shown in the rectangular area.
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An electroencephalogram (EEG) recording of a seizure from a subdural array in a patient evaluated for epilepsy surgery. The subdural electrodes record from the left anterior temporal (LAT), left middle temporal (LMT), and left posterior temporal (LPT) regions. The EEG seizure pattern is seen best in bipolar EEG channels LAT 3-4 and LMT 3-4 (rectangular areas).
