This is a summary of the American Academy of Neurology (AAN) and American Epilepsy Society (AES).

For an adult with a first seizure, the risk of a recurrence poses major concerns and raises the question of whether immediate Anti-epileptic Drug (AED) treatment is advisable.

Risk of Seizure Recurrence

Q1: For the adult who presents with an unprovoked first seizure, what are the risks for seizure recurrence?

Strong evidence

Adults presenting with an unprovoked first seizure should be informed that the chance for a recurrent seizure is greatest within the first two years after a first seizure (21 to 45%) (Level A).

Clinicians should also advise such patients that clinical factors associated with an increased risk for seizure recurrence include a prior brain insult such as a stroke or trauma (Level A) and an EEG with epileptiform abnormalities (Level A).

Moderate evidence

Clinicians should also advise such patients that clinical factors associated with an increased risk for seizure recurrence include a significant brain-imaging abnormality (Level B) and a nocturnal seizure (Level B).

Management
Q1: For the adult presenting with an unprovoked first seizure, does immediate treatment with an antiepileptic drug (AED) change the short-term (2-year) prognosis for seizure recurrence?

Moderate evidence

Clinicians should advise patients that immediate AED therapy, as compared with delay of treatment pending a second seizure, is likely to reduce the risk for a seizure recurrence in the two years subsequent to a first seizure (Level B).

Q2: For the adult presenting with an unprovoked first seizure, does immediate treatment with an AED influence prognosis such as the potential for seizure remission over the longer term (> 3 years)?

Moderate evidence

Clinicians should advise patients that over the longer term (> 3 years) immediate AED treatment is unlikely to improve the prognosis for sustained seizure remission (Level B).

Conclusion:

Clinicians' recommendations whether to initiate immediate AED treatment after a first seizure should be based on individualized assessments that weigh the risk of recurrence against the AEs of AED therapy, consider educated patient preferences, and advise that immediate treatment will not improve the long-term prognosis for seizure remission but will reduce seizure risk over the subsequent 2 years.

Physicians planning to prescribe an AED for treatment should also carefully consider the drug's specific therapeutic and AE profiles on an individualized basis. Evidence indicates that immediate AED therapy is likely to reduce seizure recurrence risk for individuals with an unprovoked first seizure.

GLOSSARY

AAN= American Academy of Neurology;

AE= Adverse event;

AED= Antiepileptic drug; 

Source:

https://n.neurology.org/content/84/16/1705    

https://www.aesnet.org/clinical-care/clinical-guidance    

https://emedicine.medscape.com/article/1184846-overview    

Note: For informational purposes only. Consult your textbook for advising your patients.