We read with great interest the evidence based recommendations by Krumholz et al. for the treatment of adults with an unprovoked first seizure, [1] an event which has profound physical, emotional, and social consequences. In this respect, we want to address some issues which may influence patient management.
Seizures following sleep deprivation, or severe physical or emotional stress, should not be considered "acute symptomatic or provoked", instead they may be interpreted as "triggered". [2] Everyone could present a seizure if a set of circumstances occurs, but some individuals have a lower seizure threshold. Despite the obvious limits in the authors' ascertainment, the coexistence of triggering factors can be taken into account to better estimate and stratify the risk of seizure recurrence, allowing for proper recommendations to the patient and guidance regarding treatment options and risk-benefit decisions.
Also, the report associated a nocturnal seizure to an increased risk of seizure recurrence; however, it should be considered that recurrence might only be nocturnal. [3,4] A university student with a first seizure after studying all night should avoid sleep deprivation rather than start pharmacological treatment.
1. Krumholz A, Wiebe S, Gronseth GS, et al. Evidence-based guideline:
Management of an unprovoked first seizure in adults: Report of the Guideline Development Subcommittee of the American Academy of Neurology and the American Epilepsy Society. Neurology 2015;84:1705-1713.
2. Lawn N, Lieblich S, Lee J, Dunne J. Are seizures in the setting of sleep deprivation provoked? Epilepsy Behav 2014;33:122-125.
3. Milton JG, Gotman J, Remillard GM, Andermann F. Timing of seizure recurrence in adult epileptic patients: a statistical analysis. Epilepsia 1987;28:471-478.
4. van Campen JS, Valentijn FA, Jansen FE, et al. Seizure occurrence and the circadian rhythm of cortisol: a systematic review. Epilepsy Behav Epub 2015 May 13.
For disclosures, please contact the editorial office at journal@neurology.org.
We read with great interest the evidence based recommendations by Krumholz et al. for the treatment of adults with an unprovoked first seizure, [1] an event which has profound physical, emotional, and social consequences. In this respect, we want to address some issues which may influence patient management.
Seizures following sleep deprivation, or severe physical or emotional stress, should not be considered "acute symptomatic or provoked", instead they may be interpreted as "triggered". [2] Everyone could present a seizure if a set of circumstances occurs, but some individuals have a lower seizure threshold. Despite the obvious limits in the authors' ascertainment, the coexistence of triggering factors can be taken into account to better estimate and stratify the risk of seizure recurrence, allowing for proper recommendations to the patient and guidance regarding treatment options and risk-benefit decisions.
Also, the report associated a nocturnal seizure to an increased risk of seizure recurrence; however, it should be considered that recurrence might only be nocturnal. [3,4] A university student with a first seizure after studying all night should avoid sleep deprivation rather than start pharmacological treatment.
1. Krumholz A, Wiebe S, Gronseth GS, et al. Evidence-based guideline: Management of an unprovoked first seizure in adults: Report of the Guideline Development Subcommittee of the American Academy of Neurology and the American Epilepsy Society. Neurology 2015;84:1705-1713.
2. Lawn N, Lieblich S, Lee J, Dunne J. Are seizures in the setting of sleep deprivation provoked? Epilepsy Behav 2014;33:122-125.
3. Milton JG, Gotman J, Remillard GM, Andermann F. Timing of seizure recurrence in adult epileptic patients: a statistical analysis. Epilepsia 1987;28:471-478.
4. van Campen JS, Valentijn FA, Jansen FE, et al. Seizure occurrence and the circadian rhythm of cortisol: a systematic review. Epilepsy Behav Epub 2015 May 13.
For disclosures, please contact the editorial office at journal@neurology.org.