Management of the first seizure: an evidence based approach.

The first seizure is more common than epilepsy. A detailed history is vital in the assessment in order to reveal unreported minor seizures such as myoclonic jerks, simple partial seizures and absences in the past. The first seizure could be provoked or unprovoked. Provoked seizures have a lower risk or recurrence. Electroencephalogram (EEG) studies and neuroimaging are essential components in the diagnostic work up. Abnormal neurological status and abnormal EEG are the most significant predictors of seizure recurrence. Antiepileptic drug (AED) treatment after the first seizure significantly reduces seizure recurrence rate in the first 2 years. However it does not appear to change the long term outlook. There are some patients who would benefit from AED treatment after the first seizure. This paper discusses the current evidence on this multifaceted clinical problem which would help formulate a rational management plan.