What is the approach to managing a patient with a first seizure in a clinic setting?

From the Guidelines

The management of a first seizure in a clinic setting should prioritize a comprehensive approach focused on diagnosis, risk assessment, and treatment decisions, with antiepileptic drug (AED) therapy not automatically initiated after a single unprovoked seizure, but considered if there is a high risk of recurrence, as supported by the Annals of Emergency Medicine guidelines 1. When evaluating a patient with a first seizure, it is essential to obtain a detailed history, including seizure description, potential triggers, medication use, and family history. A thorough physical and neurological examination is also crucial, followed by laboratory tests including complete blood count, electrolytes, glucose, calcium, and toxicology screening. An electroencephalogram (EEG) should be performed to detect epileptiform abnormalities, and brain imaging (preferably MRI) is recommended to identify structural abnormalities, as these factors can influence the risk of recurrence and guide treatment decisions 1. Some key points to consider in the management of a first seizure include:

• Identifying and treating precipitating medical conditions for patients who have had a provoked seizure, without necessarily initiating antiepileptic medication in the clinic setting 1.
• Considering antiepileptic medication for patients who experienced a first unprovoked seizure with a remote history of brain disease or injury, as the risk of seizure recurrence is higher in these patients 1.
• Weighing the benefits and risks of antiepileptic medication, as approximately one third to one half of patients with a first unprovoked seizure will have a recurrent seizure within 5 years, but outcomes at 5 years are no different if treatment is initiated within days to weeks after a seizure 1. Treatment should be individualized, taking into account the patient's specific risk factors, seizure type, and medical history, with the goal of preventing recurrent seizures while minimizing medication side effects, as supported by the highest quality evidence available 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Approach to Managing a Patient with a First Seizure

• The management of a patient with a first seizure requires a systematic diagnostic evaluation and assessment of the risks and benefits of treatment 2
• The approach should include determining whether the attack was truly a seizure, whether it was the first seizure for the patient, and why the seizure occurred 2
• A comprehensive patient care approach, including a consultation by an epileptologist, electroencephalogram (EEG), magnetic resonance imaging (MRI), and follow-up consultations, can improve diagnostic accuracy and follow-up adherence 3

Diagnostic Evaluation

• The clinical data and history from patients and witnesses are crucial in the diagnosis of first seizures 4
• Assessment tools based on factual questions and observation of patients' conversational behavior can contribute to differentiating patients with epileptic seizures from those who have experienced other types of transient loss of consciousness (TLOC) 4
• Tests, such as EEG and MRI, have a limited role in the initial diagnosis of a seizure but help determine the recurrence risk based on the cause 4

Treatment and Follow-up

• The initiation of antiepileptic therapy depends on the assessed risk for recurrence, in conjunction with a neurologist consultation 5
• Patients with a normal neurologic examination, normal laboratory results, and no signs of structural brain disease may not require hospitalization or antiepileptic medications 5
• Early specialized care, including a consultation by an epileptologist and comprehensive diagnostic evaluation, can be associated with clinical benefit in terms of diagnostic accuracy, follow-up adherence, and recurrence 3

Key Considerations

• The cause of the seizure is the most important determinant of the recurrence risk 4
• A remote symptomatic cause and detection of epileptiform discharges are associated with a recurrence risk of at least 60% and allow a diagnosis of epilepsy after a first seizure 4
• Expert history-taking continues to be the most important tool in the diagnosis of a first seizure 4