Key Practice Recommendations

These key learning points summarize the consensus- and evidence-based recommendations included in this edition. The sources listed here for each statement recommend that physicians perform or implement these actions directly in a clinical setting. A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the Strength of Recommendation Taxonomy (SORT) evidence rating system, go to https://www.aafp.org/afp/2004/0201/p548.

1. Perform neuroimaging (magnetic resonance imaging preferred) and electroencephalography after a first unprovoked seizure in adults because these studies improve diagnostic accuracy and help stratify recurrence risk.
Evidence rating: SORT A for electroencephalography; SORT B for magnetic resonance imaging
Source: Section One, reference 7

2. Evaluate for seizure mimics (eg, syncope, migraine with aura, psychogenic nonepileptic attack [functional neurologic disorder], transient ischemic attack, movement disorders) using focused history, prodromal symptoms, postevent recovery pattern, and precipitating factors.
Evidence rating: SORT B
Source: Section Two, references 9 and 14

3. Use eyewitness descriptions of preictal, ictal, and postictal behaviors, with video evidence (eg, smartphone recordings) when available to improve diagnostic accuracy and distinguish epileptic seizures from mimics such as psychogenic nonepileptic attacks, syncope variants, movement disorders, and sleep disorders.
Evidence rating: SORT B
Source: Section Two, reference 19

4. After a first unprovoked seizure, initiate antiseizure medication only when the patient has high-risk features (eg, epileptiform electroencephalography, structural lesion, prior brain injury, nocturnal seizure) because early treatment lowers short-term recurrence but does not improve long-term remission.
Evidence rating: SORT B
Source: Section Three, reference 1

5. Initiate monotherapy with a broad-spectrum antiseizure medication (eg, levetiracetam, lamotrigine) for focal and generalized tonic-clonic seizures; valproate is effective for generalized epilepsies but should be avoided in persons of childbearing potential because of teratogenicity.
Evidence rating: SORT A
Source: Section Three, reference 1

6. Counsel patients with epilepsy regarding driving restrictions and participation in high-risk occupational tasks, including the need for seizure-free intervals and state-specific legal requirements for driving.
Evidence rating: SORT B
Source: Section Four, references 32, 33, and 35