From the Guidelines
For a first seizure in a 20-year-old male, immediate activation of EMS and medical evaluation is crucial, as recommended by the 2024 American Heart Association and American Red Cross guidelines for first aid 1. The patient should be referred to a neurologist for comprehensive assessment including an electroencephalogram (EEG) and brain MRI to identify potential causes such as structural abnormalities, infections, or metabolic disturbances. Key aspects of the initial evaluation include:
- Blood tests: complete blood count, electrolytes, glucose, calcium, and toxicology screening
- Imaging: EEG and brain MRI
- Medical history: identification of potential precipitating factors or underlying conditions The patient should be advised to:
- Avoid driving until cleared by a physician (typically 3-6 months seizure-free depending on local regulations)
- Avoid alcohol
- Maintain regular sleep patterns
- Stay well-hydrated Treatment decisions depend on the risk of recurrence, which is approximately 40-50% after a first unprovoked seizure, as noted in previous studies 1. Antiepileptic medication is not typically started after a single unprovoked seizure, unless there is evidence of brain disease or injury, or a high risk of recurrence, as suggested by the clinical policy for critical issues in the evaluation and management of adult patients presenting to the emergency department with seizures 1. If the EEG shows epileptiform abnormalities or the MRI reveals a structural lesion, the recurrence risk increases significantly, potentially warranting medication. Common first-line medications for young adults include levetiracetam (Keppra) 500mg twice daily, lamotrigine (titrated slowly starting at 25mg daily), or carbamazepine 200mg twice daily, but these would only be initiated after thorough evaluation indicates a high recurrence risk or if a second seizure occurs. First aid providers should also minimize the risk of injury to the individual who is having a seizure by helping the person to the ground, placing the person on their side in the recovery position, and clearing the area around them, as recommended by the 2024 American Heart Association and American Red Cross guidelines for first aid 1.
From the Research
Evaluation and Management of First-Time Seizure
- The evaluation and management of first-time seizures in adults is crucial to determine the underlying cause and risk of recurrence 2.
- A careful history and clinical examination should guide clinicians' management plans, and electroencephalography and brain imaging may help characterize the etiology and risk of seizure recurrence.
- Antiepileptic drugs should be initiated in patients with newly diagnosed epilepsy, while in patients without an epilepsy diagnosis, the decision to prescribe drugs depends on individual risk factors for seizure recurrence and possible complications from seizures.
Risk of Seizure Recurrence
- The risk of a second seizure after a first unprovoked seizure is about 36% at 2 years and 46% after 5 years 3.
- The risk is doubled in the presence of EEG epileptiform discharges, a brain imaging abnormality, a nocturnal first seizure, or prior brain trauma.
- The risk of seizure recurrence should be discussed with the patient, and counseling about driving and lifestyle modifications should be provided early, often at the first seizure encounter 2.
Treatment Options
- Lamotrigine and levetiracetam are two antiepileptic drugs that have been shown to be effective in treating seizures, with lamotrigine monotherapy being more effective than phenytoin monotherapy in some studies 4.
- Levetiracetam may be preferred for seizure prophylaxis in patients with supratentorial neurosurgery, but its efficacy in other populations, such as those with traumatic brain injury or intracerebral hemorrhage, is less clear 5.
- The combination of transcranial magnetic stimulation and electroencephalography (TMS-EEG) may be a useful tool in measuring the effects of antiepileptic drugs, with lamotrigine and levetiracetam exerting a similar modulation of TMS-evoked EEG potentials 6.