A 25 year old patient presents to the emergency department (ED) with a first unprovoked seizure. His ED workup is normal and he is back to his baseline, and you plan to discharge the patient with outpatient follow up within 1 week. The patient is requesting to be discharged on an anti-epileptic drug (AED). What do you do?
Educate the patient about the risk of recurrence, and the possible side effects of AEDs!
The American Academy of Neurology (AAN) specifically addressed this in their 2015 guidelines. A few points to remember:
- The risk of recurrence is greatest within the first 2 years, and occurs in 21-45% of patients.
- The risk of recurrence increases with a remote brain lesion or injury, abnormal EEG, significant brain imaging abnormality or nocturnal seizures.
- AED therapy is likely to reduce the risk of a 2nd unprovoked seizure by about 35% over the next 2 years, but the delay in initiating therapy does not increase the long-term remission risk.
Is it different if the patient had multiple seizures within 24 hours?
Patients presenting with multiple seizures in a 24-hour period were as likely to have seizure recurrence as those presenting with a single seizure, irrespective of etiology or treatment.
References
Bergey GK. Management of a First Seizure.Continuum 2016;22(1):38 50.
