Question 3: For the adult presenting with an unprovoked first seizure, does immediate treatment with an AED compared with delay pending a seizure recurrence influence prognosis, such as the potential for seizure remission over the longer term (greater than three years)?
Conclusion: For adults presenting with an unprovoked first seizure, immediate AED treatment after a second seizure occurs is unlikely to achieve sustained seizure remission over the longer term (greater than three years) (Level B) compared with delayed treatment.
This is helpful when discussing patient expectations regarding long-term risks and benefits; early AED treatment may not increase the probability of being seizure-free over the long term.

Question 4: For the adult who presents with an unprovoked first seizure, what are the nature and frequency of adverse events (AEs) with AED treatment?
Conclusion: For adults with an unprovoked first seizure immediately treated with AEDs, studies indicated a wide range of predominantly mild and reversible AEs that occur in 7 to 31 percent of patients (Level B).
AEs should be considered when starting any new therapy; AEDs aren’t without risk, and these potential adverse effects should always be discussed with the patient. Although the specific AEs weren’t described in detail in the guideline, no deaths or life-threatening allergic reactions were reported. Included medications were phenytoin, phenobarbital, carbamazepine, valproic acid, and lamotrigine. Newer agents weren’t included in these data.

While this guideline doesn’t make a specific recommendation on whether or not to initiate AED therapy, it offers information to help initiate a discussion with patients and their families regarding the risks and benefits of AED therapy for a first-time seizure. It also helps frame what patients may expect in the years ahead regarding the possibility of recurrence and how AED therapy may have only a small impact over the long term. In summary, the physician and patient must make a shared decision on how to manage a first-time seizure.

Dr. Ingalsbe is a third-year emergency medicine resident physician at the Denver Health Residency in Emergency Medicine in Colorado.

ACEP Clinical Policy: First-Time Seizures

ACEP released its own clinical policy in 2014 regarding the management of seizures that focused on decisions to be made in the ED setting. The new guideline from the American Academy of Neurology is fairly in line with ACEP’s recommendations to Emergency Physicians to use individual judgement in cases of provoked or unprovoked first-time seizure.

In regard to treatment of first-time seizures, the following Level C Recommendations were made by ACEP: