Unprovoked First Seizures in Adults: Management Recommendations from the AAN
Am Fam Physician. 2015 Nov 1;92(9):835.
Key Points for Practice
• After an unprovoked seizure, the risk of recurrence is highest in the two years following the initial seizure.
• Risk factors for recurrent seizure include previous brain injury, epileptiform abnormalities found on electroencephalography, significant brain abnormality found on imaging, or nocturnal seizure
• The prognosis for sustained remission in the long term (greater than three years) is unlikely to be affected by immediate treatment with antiepileptic drugs.
From the AFP Editors
Diagnosis and management of unprovoked first seizures, which occur in approximately 150,000 adults in the United States each year, pose a challenge for physicians. Assessment, treatment, and prevention of recurrent seizures are key. This guideline from the American Academy of Neurology (AAN) provides information on prognosis and management options.
Physicians should counsel patients with an unprovoked first seizure that the risk of recurrence is highest in the two years following the initial seizure. Patients should also be informed of factors that additionally increase risk (i.e., previous brain injury [e.g., stroke], epileptiform abnormalities found on electroencephalography, significant brain abnormality found on imaging, or nocturnal seizure). The presence, or absence, of these particular factors can help physicians determine an estimated risk of recurrence and may help focus physician-patient discussions on appropriate management options.
When a patient presenting with a first seizure experiences subsequent seizures, the risk of continuing to have more seizures is high, at 57% in the first year and 73% within four years. There is a general belief that these patients should receive immediate treatment with antiepileptic drugs. However, immediate treatment in a patient presenting with a first unprovoked seizure has been questioned and is not a well-accepted practice. Indications for immediate treatment with antiepileptic drugs are mostly based on each patient's risk of recurrence.
As recommended by the AAN, another point of patient counseling should include information about how quality of life may not improve with immediate antiepileptic drug treatment vs. delayed treatment (i.e., waiting until a second seizure occurs); however, it will probably lower the patient's chance of having another seizure within the first two years. With treatment, it should be noted that the prognosis for sustained remission in the long term (greater than three years) is unlikely to be affected.
The rate of adverse events from antiepileptic drug treatment, which are usually mild and reversible, is 7% to 31%. When prescribing antiepileptic drugs, therapeutic profiles and adverse events should be considered for each patient, and his or her preferences should be taken into account.
Guideline source: American Academy of Neurology
Evidence rating system used? Yes
Literature search described? Yes
Guideline developed by participants without relevant financial ties to industry? No
Published source: Neurology, April 21, 2015;84(16):1705-1713
Available at: http://www.neurology.org/content/84/16/1705.full
Coverage of guidelines from other organizations does not imply endorsement by AFP or the AAFP.
This series is coordinated by Sumi Sexton, MD, Associate Deputy Editor.
A collection of Practice Guidelines published in AFP is available at https://www.aafp.org/afp/practguide.
Copyright © 2015 by the American Academy of Family Physicians.
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