From the Guidelines
A first-time seizure workup should include a comprehensive evaluation to determine the cause and risk of recurrence, as recommended by the most recent clinical policy approved by the ACEP board of directors in 2024 1. The evaluation should begin with a detailed history focusing on seizure description, witnesses' accounts, precipitating factors, medical history, medications, substance use, and family history of seizures.
- Perform a thorough physical and neurological examination to identify any potential underlying causes.
- Laboratory tests should include:
- Complete blood count
- Comprehensive metabolic panel
- Glucose
- Calcium
- Magnesium
- Toxicology screen
- Antiepileptic drug levels if relevant
- Neuroimaging with MRI brain (preferred) or CT scan is essential to identify structural abnormalities, as emphasized in the ACR appropriateness criteria for seizures in children 1.
- An electroencephalogram (EEG) should be performed within 24-48 hours of the seizure to detect epileptiform abnormalities, which increases the likelihood of seizure recurrence.
- Consider lumbar puncture if infection is suspected.
- Antiepileptic medication is typically not initiated after a single unprovoked seizure unless there are risk factors for recurrence, such as abnormal EEG, structural brain lesion, or significant neurological abnormality.
- Counsel patients about seizure precautions including avoiding driving (typically for 3-6 months depending on jurisdiction), swimming alone, operating dangerous machinery, and working at heights. This comprehensive approach helps determine seizure etiology and guides appropriate management to prevent recurrence, ultimately reducing morbidity, mortality, and improving quality of life.
From the Research
First-Time Seizure Workup
- The evaluation of a first-time seizure is crucial in determining the underlying cause and guiding further management [(2,3,4,5,6)].
- A thorough patient history and physical examination are essential in directing the type and timing of laboratory and imaging studies [(2,3,4,5,6)].
Laboratory and Imaging Studies
- Electroencephalography (EEG) is recommended for patients presenting with a first seizure [(2,4,5,6)].
- Neuroimaging, preferably with magnetic resonance imaging (MRI), is recommended for adults and children with risk factors such as head trauma, focal neurologic deficits, or a history of malignancy [(2,4,5)].
- Laboratory tests, such as blood glucose and electrolyte panels, may be helpful in identifying underlying metabolic derangements [(2,3,5)].
Management and Treatment
- Patients with a normal neurologic examination, normal test results, and no structural brain disease do not require hospitalization or antiepileptic medications [(2,3,4,6)].
- Initiation of antiepileptic therapy depends on the assessed risk for recurrence, in conjunction with a neurologist consultation [(3,4,6)].
- Counseling about driving and lifestyle modifications should be provided early, often at the first seizure encounter [(4,6)].