You Just Had Your First Seizure - Now What?

Every year, millions of people worldwide experience a seizure for the first time.  Of those, it’s estimated that less than half (about one in 26 Americans) will go on to develop epilepsy, traditionally meaning more than one seizure that occur without other explanation.   

The first step is to see if what was actually a seizure or a seizure mimic.  The next step should be to ensure that this seizure is in fact the first.

 Not all seizures cause obvious shaking-- some just cause unusual smells, or episodes of staring into space. 

If a seizure is confirmed, doctors must try to find the cause.  Sometimes, the cause of the seizure is obvious to a doctor.  For example, low blood sugar or alcohol withdrawal can cause seizures in an otherwise healthy person. Most physicians opt against treating with an antiepileptic drug (AED) if the cause of the seizure is readily apparent and as easily fixable as not letting blood sugar get too low, and don’t drink so much alcohol. 

Most doctors also have a good sense of what to do if someone has already had more than one unexplained seizure—in this case, a medication should be started because the risk of further seizures is quite high (about 75 percent over the next four years).  

The trickier situation is when someone has had his or her first seizure and that seizure is unexplained.

  For a long time, it was thought that such a person should not receive medication, because until they had another unexplained seizure, they did not meet the standard definition of epilepsy. 

“Many clinicians have been trained that a single seizure is not epilepsy, and should therefore not be treated,” says Dr. Jaqueline French, who helped to author new guidelines on first seizure management.

 “A lot of doctors have been taught to … have a ‘watching-and-waiting stance. ’” On the other hand, Dr. French says of physicians “We often treat people not because of what they have, but because of what we don’t want them to have.”  Doctors don’t always wait for something bad to happen before they try to prevent it with medication. 

Furthermore, the standard definition of epilepsy may be changing based off recommendations of International League Against Epilepsy (ILAE), which now suggests that the standard definition of epilepsy should be expanded to include those with just one unprovoked seizure who also have a high risk of seizure recurrence.  The problem, then, is defining who is at high risk of having another seizure.

In what Dr. French’s fellow author Allan Krumholz, MD called a “valuable new guideline that could change the approach many doctors take to treating a first seizure and could improve patients’ lives,” the American Academy of Neurology published a new set of recommendations on how people should manage a first unexplained seizure in April of 2015.

After carefully reviewing over 40 scientific papers (selected from over 2,000 such publications), the creators of the guideline discovered that the risk of having another seizure ranged from about one-in-five to one-in-two.  In general, the risk of having another seizure is greatest within two years of the first attack.

 The risk is highest for those with a recognized brain disorder such as tumor, stroke or head injury—though the authors excluded patients who suffered those problems within a week of the first seizure, in which case it may be better not to prescribe a drug but instead wait and see if seizures continue. 

Neurological tests such as an electroencephalogram (EEG) or magnetic resonance imaging (MRI) may also suggest a higher risk of recurrent seizure if abnormal. 

Prescribing an antiepileptic medication was suggested to decrease the risk of someone’s having another seizure within the first two years of his or her first attack.  The risk fell by about 35 percent.  On the other hand, there was also some evidence that the overall quality of life in those patients was not improved.  Furthermore, it appeared that immediate prescription of medication was unlikely to improve someone’s chance of remaining seizure free in the long run.

The authors also recognized that medications are not without risk.  About 7 to 35 percent of those who were prescribed medication following their first unexplained seizure experienced some side effects, though most of these were mild in nature or reversible. 

So the answer to what to do for someone’s first seizure is: it depends.  It depends on what an EEG shows, whether that person had an old brain injury of some sort, and perhaps most importantly, it depends on what that person feels they need after hearing about all the risks and benefits of medication.

Sources:

Fisher, R.S., Acevedo, C., Arzimanoglou, A., Bogacz, A., Cross, J.H., Elger, C.E., Engel, J., Jr., Forsgren, L., French, J.A., Glynn, M., Hesdorffer, D.C., Lee, B.I., Mathern, G.W., Moshe, S.L., Perucca, E., Scheffer, I.E., Tomson, T., Watanabe, M., Wiebe, S., 2014. ILAE official report: a practical clinical definition of epilepsy. Epilepsia 55, 475-482.

Krumholz, A., Wiebe, S., Gronseth, G.S., Gloss, D.S., Sanchez, A.M., Kabir, A.A., Liferidge, A.T., Martello, J.P., Kanner, A.M., Shinnar, S., Hopp, J.L., French, J.A., 2015. Evidence-based guideline: Management of an unprovoked first seizure in adults. Neurology 84, 17705-11713.

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