What is the treatment for a patient who has experienced a single seizure?

Treatment Approach for a Single Seizure

For patients who have experienced a single unprovoked seizure, antiepileptic medication should not be initiated unless there are specific risk factors for recurrence such as a remote history of brain disease or injury. 1

Initial Evaluation

When a patient presents after a single seizure, the following evaluation should be performed:

• Rapid assessment of airway, breathing, and circulation 1
• Neurological examination to determine focal deficits and seizure severity 1
• Assessment of vital signs including heart rate, blood pressure, temperature, and oxygen saturation 1
• Immediate brain imaging with non-contrast CT for first-time seizures 2
• Basic laboratory tests including:
  • Electrolytes
  • Random glucose
  • Complete blood count
  • Coagulation status (INR, aPTT)
  • Creatinine 1

Classification of Seizures

The treatment approach depends on whether the seizure is:

1. Provoked seizure: Occurs due to an identifiable trigger such as metabolic disturbance, medication effect, alcohol withdrawal, or acute illness 3

2. Unprovoked seizure: Occurs without an identifiable acute precipitating factor and may be:

   • Remote symptomatic (due to a static brain injury)
   • Progressive symptomatic (due to an ongoing brain condition) 4

Treatment Recommendations

For Provoked Seizures

• Do not initiate antiepileptic medication 1
• Identify and treat the underlying precipitating condition 1, 3
• Short-acting medications (e.g., lorazepam IV) may be used if seizures are not self-limiting 1

For Unprovoked Seizures

Without Evidence of Brain Disease or Injury

• Do not initiate antiepileptic medication in the emergency department 1
• Approximately one-third to one-half of patients with a first unprovoked seizure will have a recurrent seizure within 5 years 1
• The strategy of waiting until a second seizure before initiating antiepileptic medication is considered appropriate 1
• The number needed to treat (NNT) to prevent a single seizure recurrence in the first 2 years is approximately 14 patients 1

With Remote History of Brain Disease or Injury

• Consider initiating antiepileptic medication or defer in coordination with other providers 1
• Patients with a history of stroke, trauma, tumor, or other CNS disease/injury have a higher risk of recurrence 1, 4
• The number needed to treat (NNT) to prevent a single additional seizure in the first year is approximately 5 1

Disposition

• Patients with a first unprovoked seizure who have returned to their clinical baseline do not require hospital admission 1, 2
• Discharge criteria include:
  • Return to baseline mental status
  • Single self-limited seizure with no recurrence
  • Normal or non-acute findings on neuroimaging
  • Reliable follow-up available
  • A responsible adult to observe the patient 2

Follow-up Care

• Arrange follow-up with neurology 2
• Provide education about seizure precautions and safety measures 2
• Advise on driving restrictions according to local laws 2
• Instruct on seizure triggers to avoid 2

Special Considerations

• Seizures in stroke patients: A single, self-limiting seizure occurring at the onset or within 24 hours after an ischemic stroke should not be treated with long-term anticonvulsant medications 1

• Prophylactic use: Prophylactic use of anticonvulsant medications in patients with ischemic stroke is not recommended and may have negative effects on neurological recovery 1

• High risk for recurrence: Consider antiepileptic drug therapy for patients with high risk of recurrence, including those with:

  • History of brain insult
  • Epileptiform abnormalities on EEG
  • Structural lesion on imaging 2, 4

Remember that while all patients with epilepsy experience seizures, not all individuals with seizures have epilepsy. Epilepsy is defined as two or more unprovoked seizures, and treatment approaches differ between a single seizure and established epilepsy 4.