From the Guidelines
After a first short-lasting seizure in a 10-year-old boy with normal past medical history and normal physical exam, observation without starting antiepileptic medication is recommended. The child should be referred to a pediatric neurologist for evaluation, which typically includes an electroencephalogram (EEG) to assess for epileptiform activity and often brain imaging such as MRI to rule out structural abnormalities, as suggested by the most recent guidelines 1. Parents should be educated about seizure first aid, including placing the child on their side during a seizure, not putting anything in their mouth, timing the seizure, and seeking emergency care for seizures lasting more than 5 minutes.
The risk of recurrence after a first unprovoked seizure is approximately 30-50%, with most recurrences happening within the first year, as noted in previous studies 1. Treatment with antiepileptic drugs is generally not initiated after a single seizure because the potential side effects of long-term medication may outweigh the benefits, especially since many children will never have another seizure. However, if the EEG shows epileptiform abnormalities or if imaging reveals a structural lesion, the risk of recurrence increases, and medication might then be considered, as indicated by the clinical policy for adult patients presenting to the emergency department with seizures 1.
Key considerations in the management of this patient include:
- Referral to a pediatric neurologist for further evaluation and guidance
- Education on seizure first aid and emergency care
- Monitoring for signs of seizure recurrence or other neurological abnormalities
- Consideration of antiepileptic medication if there are epileptiform abnormalities on EEG or structural lesions on imaging, based on the most recent and highest quality evidence available 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Recommended Evaluation and Management
After a first-time, short-lasting seizure in a 10-year-old boy with a normal past medical history (PMH) and a normal physical examination, the following steps are recommended:
- Identification of provoking factors, such as fever, illness, head trauma, electrolyte disturbance, or central nervous system infection, is important for determining prognosis and likelihood of recurrence 2
- A history should be taken and a neurologic examination performed to determine whether the event was a seizure 2, 3
- If seizure is confirmed, it should be determined whether it was a first seizure and was provoked or unprovoked 2
- An electroencephalogram (EEG) performed during wakefulness and sleep is recommended for children with a first unprovoked seizure 2
- For children with new-onset seizures, particularly focal seizures or status epilepticus, neuroimaging with magnetic resonance imaging (MRI) study is recommended 2
Risk Factors for Epilepsy Development
Risk factors for epilepsy development include:
- A history of febrile seizures
- Status epilepticus
- A family history of epilepsy
- Developmental delay
- Abnormal neurologic examination results 2
Antiepileptic Drug Treatment
The decision to initiate antiepileptic drug treatment should be individualized, but should be strongly considered after 2 unprovoked seizures or after 1 unprovoked seizure that occurred during sleep and/or in the presence of epileptiform activity on an EEG and/or in the presence of a structural lesion on the brain MRI 4
- For focal epilepsy, oxcarbazepine and lamotrigine are first-line therapy, while levetiracetam can be also considered if there is no history of psychiatric disorder 4
- For generalized epilepsy, the selection of the antiepileptic drug is based on the type of epilepsy syndrome and the patient's sex, age, and psychiatric history 4