Should patients with new onset seizures and no obvious cause be started on anti-epileptic (AED) medication upon discharge from the Emergency Department (ED)?

From the Guidelines

Patients with new onset seizures and no obvious cause should generally not be started on anti-epileptic medication (AED) upon discharge from the Emergency Department, as the risk of seizure recurrence is relatively low and AEDs carry significant side effects 1. Instead, these patients should be referred for urgent outpatient neurology follow-up, typically within 1-2 weeks, for comprehensive evaluation including EEG and possibly MRI before initiating long-term treatment. The decision to start AEDs should be individualized and typically made by a neurologist after considering the risk of seizure recurrence, which is approximately 40-50% after a first unprovoked seizure 1. Some key points to consider include:

• The number needed to treat (NNT) to prevent a single additional seizure in the following first year is approximately 5 1
• Immediate AED treatment may be warranted in specific situations such as patients with structural brain abnormalities, abnormal EEG findings, nocturnal seizures, or status epilepticus
• When treatment is indicated, common first-line medications include levetiracetam (Keppra) 500mg twice daily, lamotrigine with gradual titration starting at 25mg daily, or carbamazepine 200mg twice daily, with medication choice depending on seizure type, patient comorbidities, and potential side effects
• Starting a patient on lifelong medication requires careful consideration of the diagnosis, seizure classification, and patient-specific factors that are best addressed in a non-emergency setting 1.

From the Research

Decision to Start Anti-Epileptic Medication

The decision to start anti-epileptic medication in patients with new onset seizures and no obvious cause is complex and should be informed by various factors, including the risk of recurrence, the type of seizure, and the patient's overall health status.

• The risk of recurrence after a single unprovoked seizure is approximately 50% 2.
• Studies have shown that anti-epileptic drug treatment can reduce the risk of a second seizure, but does not alter longer-term seizure outcomes 3.
• A prognostic model has been developed to identify patients at low, medium, and high risk of recurrence, which can inform treatment decisions 3.
• For patients presenting with two or more seizures, treatment should be initiated if the seizures were of significant symptomatology and occurred over a period of less than 6-12 months 3.

Factors Influencing Treatment Decisions

Several factors can influence the decision to start anti-epileptic medication, including:

• The type of seizure: patients with partial onset seizures may be started on carbamazepine or lamotrigine, while those with generalized onset seizures may be started on sodium valproate 4.
• The patient's overall health status: patients with certain comorbidities or adverse effect profiles may require careful selection of anti-epileptic medication 5.
• The risk of intractability: patients with symptomatic aetiology, localization-related epilepsy, or an early unfavourable course may require early and aggressive treatment 2.

Current Guidelines and Recommendations

Current guidelines recommend that patients with new onset seizures and no obvious cause should undergo electroencephalography and epilepsy protocol-specific magnetic resonance imaging to determine the risk of recurrence and the need for long-term treatment 5.

• The American Academy of Neurology and the International League Against Epilepsy have published guidelines for the treatment of new onset seizures, which recommend careful selection of anti-epileptic medication and consideration of the patient's overall health status 5.