New Guideline on First Seizure in Adults

The American Academy of Neurology and the American Epilepsy Society have released a new guideline on how to treat a first seizure, which affects 1 in 10 people worldwide over a lifetime.

“This is a valuable new guideline that could change the approach many doctors take to treating a first seizure and could improve patients’ lives,” said guideline author Allan Krumholz, MD, Professor of Neurology at the University of Maryland School of Medicine. “About 150,000 adults have an unprovoked first seizure in the United States each year. Even 1 seizure is traumatic and affects a person’s life in many social ways, such as driving a car, employment options, falling risks and the fear of having another seizure in public. This guideline clarifies when risk factors put individuals at greater risk.”

Epilepsy is defined as 1 or more seizures with a high likelihood of recurrence, not due to another immediately triggering cause, such as low blood sugar, according to The International League Against Epilepsy.

The guideline, which reviewed all available evidence, found that taking epilepsy drugs immediately after a first seizure may reduce the risk of having another seizure. The decision to treat after a first seizure is complex because doctors must consider the risks and benefits for each individual patient.

The guideline states that “adults with an unprovoked first seizure should be informed that their seizure recurrence risk is greatest early within the first 2 years (21% to 45%) and clinical variables associated with increased risk may include a prior brain insult, an EEG with epileptiform abnormalities, a significant brain-imaging abnormality, and a nocturnal seizure.”

The guideline found moderate evidence that “immediate antiepileptic drug (AED) therapy, as compared with delay of treatment pending a second seizure, is likely to reduce recurrence risk within the first 2 years but may not improve quality of life.”

There is also moderate evidence to show that “over a longer term (3 years), immediate AED treatment is unlikely to improve prognosis as measured by sustained seizure remission.”

The guideline notes that “patients should be advised that risk of AED adverse events may range from 7% to 31% and that these adverse events are likely predominantly mild and reversible.”

“This guideline does not give a simple, black-and-white recommendation whether an adult should immediately be started on an epilepsy drug,” said Jacqueline French, MD, Professor, Department of Neurology, at New York University Langone Medical Center and co-director of the Epilepsy Research and Epilepsy Clinical Trials at the New York University Comprehensive Epilepsy Center. “What is most important is that the decision whether to immediately treat a first seizure requires meaningful conversation between patient and doctor so that the patient’s individual circumstances, balance of risks and benefits, and personal preferences are understood and accounted for.”

The American Neurological Association and the World Federation of Neurology endorsed the guideline.

The guideline was presented on April 20, 2015 at the AAN Annual Meeting in Washington, DC and simultaneously published online in the journal Neurology.