Considerations in the Treatment of a First Unprovoked Seizure

 

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ABSTRACT

Treatment issues following a first unprovoked seizure are discussed, using an approach that emphasizes weighing the relative risks and benefits of the therapeutic decisions. The majority of children and adults who present with a first unprovoked seizure will not experience further seizures. Both seizures and the therapies available carry some risk, and optimal patient care requires careful balancing of these risks and benefits. Treatment with antiepileptic drugs reduces recurrence risk but does not alter long-term prognosis. In general, treatment should be deferred until a second seizure has occurred. Whatever the decision, it should be made jointly by the medical providers and the patient and family after careful discussion, including assessment of risk and impact of seizure recurrence. Providing appropriate education and counseling to patients and families may be the most important aspect of treatment of a first unprovoked seizure.

REFERENCES

• 1 Gowers W R. Epilepsy and Other Chronic Convulsive Disorders. London; J&A Churchill 1881
  Google Scholar
• 2 Sander J W, Hart Y M, Johnson A L, Shorvon S D. National General Practice Study of Epilepsy: newly diagnosed epileptic seizures in a general population.  Lancet. 1990;  336 1267-1271
  CrossrefPubMedGoogle Scholar
• 3 Groupe CAROLE . Treatment of newly diagnosed epileptic crisis: a French experience.  Rev Neurol (Paris). 2001;  157 1500-1512
  PubMedGoogle Scholar
• 4 [No authors listed.] . Guidelines for epidemiologic studies on epilepsy. Commission on Epidemiology and Prognosis, International League Against Epilepsy.  Epilepsia. 1993;  34 592-596
  CrossrefPubMedGoogle Scholar
• 5 Shinnar S, Berg A T, Moshé S L et al.. Risk of recurrence following a first unprovoked seizure in childhood: a prospective study.  Pediatrics. 1990;  85 1076-1085
  CrossrefPubMedGoogle Scholar
• 6 Shinnar S, Berg A T, Moshe S L, Shinnar R. How long do new-onset seizures in children last?.  Ann Neurol. 2001;  49 659-664
  CrossrefPubMedGoogle Scholar
• 7 Hauser W A, Anderson V E, Loewenson R B, McRoberts S M. Seizure recurrence after a first unprovoked seizure.  N Engl J Med. 1982;  307 522-528
  CrossrefPubMedGoogle Scholar
• 8 Annegers J F, Shirts S B, Hauser W A, Kurland L T. Risk of recurrence after an initial unprovoked seizure.  Epilepsia. 1986;  27 43-50
  CrossrefPubMedGoogle Scholar
• 9 Berg A T, Shinnar S. The risk of seizure recurrence following a first unprovoked seizure: a quantitative review.  Neurology. 1991;  41 965-972
  CrossrefPubMedGoogle Scholar
• 10 Camfield P R, Camfield C S, Dooley J M, Tibbles J AR, Fung T, Garner B. Epilepsy after a first unprovoked seizure in childhood.  Neurology. 1985;  35 1657-1660
  PubMedGoogle Scholar
• 11 Camfield P, Camfield C, Dooley J et al.. A randomized study of carbamazepine versus no medication following a first unprovoked seizure in childhood.  Neurology. 1989;  39 851-852
  PubMedGoogle Scholar
• 12 Das C P, Sawhney I M, Lal V, Prabhakar S. Risk of recurrence of seizures following single unprovoked idiopathic seizure.  Neurol India. 2000;  48 357-360
  PubMedGoogle Scholar
• 13 Hauser W A, Rich S S, Annegers J F, Anderson V E. Seizure recurrence after a first unprovoked seizure: an extended follow-up.  Neurology. 1990;  40 1163-1170
  PubMedGoogle Scholar
• 14 Stroink H, Brouwer O F, Arts W F, Geerts A T, Peters A C, van Donselaar C A. The first unprovoked, untreated seizure in childhood: a hospital based study of the accuracy of the diagnosis, rate of recurrence, and long term outcome after recurrence. Dutch study of epilepsy in childhood.  J Neurol Neurosurg Psychiatry. 1998;  64 595-600
  CrossrefPubMedGoogle Scholar
• 15 van Donselaar C A, Brouwer O F, Geerts A T, Arts W F, Stroink H, Peters A C. Clinical course of untreated tonic-clonic seizures in childhood: prospective, hospital-based study.  BMJ. 1997;  314 401-404
  PubMedGoogle Scholar
• 16 Elwes R DC, Chesterman P, Reynolds E H. Prognosis after a first untreated tonic-clonic seizure.  Lancet. 1985;  2 752-753
  PubMedGoogle Scholar
• 17 First Seizure Trial Group . Randomized clinical trial on the efficacy of antiepileptic drugs in reducing the risk of relapse after a first unprovoked tonic-clonic seizure.  Neurology. 1993;  43 478-483
  PubMedGoogle Scholar
• 18 Hirtz D G, Ellenberg J H, Nelson K B. The risk of recurrence of nonfebrile seizures in children.  Neurology. 1984;  34 637-641
  PubMedGoogle Scholar
• 19 Lindsten H, Stenlund H, Forsgren L. Seizure recurrence in adults after a newly diagnosed unprovoked epileptic seizure.  Acta Neurol Scand. 2001;  104 202-207
  CrossrefPubMedGoogle Scholar
• 20 Wiebe S. An evidence-based approach to the first unprovoked seizure.  Can J Neurol Sci. 2002;  29 120-124
  PubMedGoogle Scholar
• 21 van Donselaar C A, Geerts A T, Schimsheimer R J. Idiopathic first seizure in adult life: who should be treated?.  BMJ. 1991;  302 620-623
  PubMedGoogle Scholar
• 22 Hopkins A, Garman A, Clarke C. The first seizure in adult life: value of clinical features, electroencephalography, and computerized tomographic scanning in prediction of seizure recurrence.  Lancet. 1988;  1 721-726
  PubMedGoogle Scholar
• 23 Marson A, Jacoby A, Johnson A, Kim L, Gamble C, Chadwick D. Medical Research Council MESS Study Group . Immediate versus deferred antiepileptic drug treatment for early epilepsy and single seizures: a randomized controlled trial.  Lancet. 2005;  365 2007-2013
  CrossrefPubMedGoogle Scholar
• 24 Shinnar S, Berg A T, O'Dell C, Newstein D, Moshe S L, Hauser W A. Predictors of multiple seizures in a cohort of children prospectively followed from the time of their first unprovoked seizure.  Ann Neurol. 2000;  48 140-147
  CrossrefPubMedGoogle Scholar
• 25 Shinnar S, Berg A T, Moshe S L et al.. The risk of seizure recurrence following a first unprovoked afebrile seizure in childhood: an extended follow-up.  Pediatrics. 1996;  98 216-225
  PubMedGoogle Scholar
• 26 Camfield P, Camfield C. Epilepsy can be diagnosed when the first two seizures occur on the same day.  Epilepsia. 2000;  41 1230-1233
  CrossrefPubMedGoogle Scholar
• 27 Kho L K, Lawn N D, Dunne J W, Linto J. First seizure presentation: do multiple seizures within 24 hours predict recurrence?.  Neurology. 2006;  67 1047-1049
  CrossrefPubMedGoogle Scholar
• 28 Haut S R, Legatt A D, O'Dell C, Moshé S L, Shinnar S. Seizure lateralization during EEG monitoring in patients with bilateral foci: the cluster effect.  Epilepsia. 1997;  38 937-940
  CrossrefPubMedGoogle Scholar
• 29 Hirtz D, Ashwal S, Berg A et al.. Practice parameter: evaluating a first nonfebrile seizure in children: report of the quality standards subcommittee of the American Academy of Neurology, the Child Neurology Society, and the American Epilepsy Society.  Neurology. 2000;  55 616-623
  CrossrefPubMedGoogle Scholar
• 30 Shinnar S, Berg A T, O'Dell C, Newstein D, Moshe S L, Hauser W A. Predictors of multiple seizures in a cohort of children prospectively followed from the time of their first unprovoked seizure.  Ann Neurol. 2000;  48 140-147
  CrossrefPubMedGoogle Scholar
• 31 [No authors listed.] . Proposal for revised classification of epilepsies and epileptic syndromes. Commission on classification and terminology of the International League Against Epilepsy.  Epilepsia. 1989;  30 389-399
  CrossrefPubMedGoogle Scholar
• 32 Roger J, Bureau M, Dravet C, Genton P, Tassinari CA, Wolf P Epileptic Syndromes in Infancy, Childhood and Adolescence. 3rd ed. London; John-Libbey Eurotext 2002
  Google Scholar
• 33 Shinnar S, Kang H, Berg A T, Goldensohn E S, Hauser W A, Moshe S L. EEG abnormalities in children with a first unprovoked seizure.  Epilepsia. 1994;  35 471-476
  CrossrefPubMedGoogle Scholar
• 34 van Donselaar C A, Schimsheimer R J, Geerts A T, Declerck A C. Value of the electroencephalogram in adult patients with untreated idiopathic first seizures.  Arch Neurol. 1992;  49 231-237
  CrossrefPubMedGoogle Scholar
• 35 Kim L G, Johnson T L, Marson A G, Chadwick D W. Prediction of risk of seizure recurrence after a single seizure and early epilepsy: further results from the MESS trial.  Lancet Neurol. 2006;  5 317-322
  CrossrefPubMedGoogle Scholar
• 36 Hauser W A, Rich S S, Lee J R, Annegers J F, Anderson V E. Risk of recurrent seizures after two unprovoked seizures.  N Engl J Med. 1998;  338 429-434
  CrossrefPubMedGoogle Scholar
• 37 Shinnar S, Berg A T, Ptachewich Y, Alemany M. Sleep state and the risk of seizure recurrence following a first unprovoked seizure in childhood.  Neurology. 1993;  43 701-706
  PubMedGoogle Scholar
• 38 Musicco M, Beghi E, Solari A, Viani F. for the First Seizure Trial Group (FIRST Group) . Treatment of first tonic-clonic seizure does not improve the prognosis of epilepsy.  Neurology. 1997;  49 991-998
  PubMedGoogle Scholar
• 39 Chandra B. First seizure in adults: to treat or not to treat.  Clin Neurol Neurosurg. 1992;  94 S61-S63
  PubMedGoogle Scholar
• 40 Gilad R, Lampl Y, Gabbay U, Eshel Y, Sarova-Pinhas I. Early treatment of a single generalized tonic-clonic seizure to prevent recurrence.  Arch Neurol. 1996;  53 1149-1152
  PubMedGoogle Scholar
• 41 Leone M A, Solari A, Beghi E. FIRST Group . Treatment of the first tonic-clonic seizure does not affect long-term remission of epilepsy.  Neurology. 2006;  67 2227-2229
  CrossrefPubMedGoogle Scholar
• 42 Shinnar S, Berg A T. Does antiepileptic drug therapy prevent the development of “chronic” epilepsy?.  Epilepsia. 1996;  37 701-708
  CrossrefPubMedGoogle Scholar
• 43 Hirtz D, Berg A, Bettis D et al.. Practice parameter: treatment of the child with a first unprovoked seizure: report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society.  Neurology. 2003;  60 166-175
  CrossrefPubMedGoogle Scholar
• 44 O'Dell C, Shinnar S. Initiation and discontinuation of antiepileptic drugs.  Neurol Clin. 2001;  19 289-311
  CrossrefPubMedGoogle Scholar
• 45 Vining E P, Mellits E D, Dorsen M M et al.. Psychologic and behavioral effects of antiepileptic drugs in children: a double-blind comparison between phenobarbital and valproic acid.  Pediatrics. 1987;  80 165-174
  PubMedGoogle Scholar
• 46 Petty S J, Paton L M, O'Brien T J et al.. Effect of antiepileptic medication on bone mineral measures.  Neurology. 2005;  65 1358-1365
  CrossrefPubMedGoogle Scholar
• 47 Reynolds E H, Trimble M R. Adverse neuropsychiatric effects of anticonvulsant drugs.  Drugs. 1985;  29 570-581
  CrossrefPubMedGoogle Scholar
• 48 Yerby M S. Teratogenic effects of antiepileptic drugs: what do we advise patients?.  Epilepsia. 1997;  38 957-958
  PubMedGoogle Scholar
• 49 Hoare P. Does illness foster dependency? A study of epileptic and diabetic children.  Dev Med Child Neurol. 1984;  26 20-24
  PubMedGoogle Scholar
• 50 Spitz M C. Injuries and death as a consequence of seizures in people with epilepsy.  Epilepsia. 1998;  39 904-907
  CrossrefPubMedGoogle Scholar
• 51 Neufeld M Y, Vishne T, Chistik V, Korczyn A D. Life-long history of injuries related to seizures.  Epilepsy Res. 1999;  34 123-127
  CrossrefPubMedGoogle Scholar
• 52 Shinnar S, Berg A T, Moshe S L, Shinnar R. How long do new-onset seizures in children last?.  Ann Neurol. 2001;  49 659-664
  CrossrefPubMedGoogle Scholar
• 53 Jacoby A, Baker G, Chadwick D, Johnson A. The impact of counseling with a practical statistical model on a patient's decision-making about treatment with epilepsy: findings from a pilot study.  Epilepsy Res. 1993;  16 207-214
  CrossrefPubMedGoogle Scholar
• 54 Jacoby A, Johnson A, Chadwick D. Psychosocial outcomes of antiepileptic drug discontinuation.  Epilepsia. 1992;  33 1123-1131
  CrossrefPubMedGoogle Scholar
• 55 Freeman J M, Tibbles J, Camfield C, Camfield P. Benign epilepsy of childhood: a speculation and its ramifications.  Pediatrics. 1987;  79 864-868
  PubMedGoogle Scholar
• 56 Berg A T, Shinnar S. Do seizures beget seizures? An assessment of the clinical evidence in humans.  J Clin Neurophysiol. 1997;  14 102-110
  PubMedGoogle Scholar
• 57 Chadwick D, Taylor J, Johnson T. Outcomes after seizure recurrence in people with well-controlled epilepsy and the factors that influence it. The MRC Antiepileptic Drug Withdrawal Group.  Epilepsia. 1996;  37 1043-1050
  PubMedGoogle Scholar
• 58 Sander J WAS. Some aspects of prognosis in the epilepsies: a review.  Epilepsia. 1993;  34 1007-1016
  CrossrefPubMedGoogle Scholar
• 59 Ambrosetto G, Tassinari C A. Antiepileptic drug treatment of benign childhood epilepsy with rolandic spikes: is it necessary?.  Epilepsia. 1990;  31 802-805
  CrossrefPubMedGoogle Scholar
• 60 Annegers J F, Hauser W A, Elveback L R. Remission of seizures and relapse in patients with epilepsy.  Epilepsia. 1979;  20 729-737
  CrossrefPubMedGoogle Scholar
• 61 Andersson T, Braathen G, Persson A et al.. A comparison between one and three years of treatment in uncomplicated childhood epilepsy: a prospective study, II: the EEG as predictor of outcome after withdrawal of treatment.  Epilepsia. 1997;  38 225-232
  CrossrefPubMedGoogle Scholar

Sheryl R HautM.D. 

Epilepsy Management Center, Montefiore Medical Center

111 East 210th Street, Bronx, NY 10467-2490

Email: haut@aecom.yu.edu