Abstract
Objective: To provide evidence-based recommendations for treatment of adults with an unprovoked first seizure.
Methods: We defined relevant questions and systematically reviewed published studies according to the American Academy of Neurology's classification of evidence criteria; we based recommendations on evidence level.
Results and recommendations: Adults with an unprovoked first seizure should be informed that their seizure recurrence risk is greatest early within the first 2 years (21%–45%) (Level A), and clinical variables associated with increased risk may include a prior brain insult (Level A), an EEG with epileptiform abnormalities (Level A), a significant brain-imaging abnormality (Level B), and a nocturnal seizure (Level B). 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 (Level B) but may not improve quality of life (Level C). Over a longer term (>3 years), immediate AED treatment is unlikely to improve prognosis as measured by sustained seizure remission (Level B). Patients should be advised that risk of AED adverse events (AEs) may range from 7% to 31% (Level B) and that these AEs are likely predominantly mild and reversible. Clinicians' recommendations whether to initiate immediate AED treatment after a first seizure should be based on individualized assessments that weigh the risk of recurrence against the AEs of AED therapy, consider educated patient preferences, and advise that immediate treatment will not improve the long-term prognosis for seizure remission but will reduce seizure risk over the subsequent 2 years.
GLOSSARY
- AAN=
- American Academy of Neurology;
- AE=
- adverse event;
- AED=
- antiepileptic drug;
- CI=
- confidence interval;
- ILAE=
- International League Against Epilepsy;
- QOL=
- quality of life
Footnotes
Approved by the Guideline Development Subcommittee on November 16, 2013; by the Practice Committee on January 20, 2014; by the AES Board of Directors on February 13, 2014; and by the AANI Board of Directors on December 1, 2014.
This guideline was endorsed by the World Federation of Neurology on May 20, 2014, and by the American Neurological Association on May 21, 2014.
Go to Neurology.org for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.
Supplemental data at Neurology.org
- Received March 10, 2014.
- Accepted in final form October 30, 2014.
- © 2015 American Academy of Neurology
Disputes & Debates: Rapid online correspondence
- Commentary authors' response to Krumholz
- Guideline authors' response to Neurology: Clinical Practice commentary by Drs. Cole and Cascino
- The management of an unprovoked first seizure in adults
- Authors' response to Dr. Lattanzi et al.
- Authors' response to Dr. Sethi's correspondence
- Unprovoked first seizure: to treat or not to treat?
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