We see a fair bit of ostensibly “first-time” seizure in the Emergency Department. With some room for nuance and debate, general practice is typically still to defer initiation of anti-epileptic therapy.
This decision analysis in the neurology literature ultimately comes to the alternative conclusion – initiation of AEDs is reasonable even absent a clear or likely diagnosis of epilepsy. Based on their cases and parameters regarding seizure recurrence, the degradation of quality-of-life relating to seizure recurrence, and the features of modern AEDs, these authors find in favor of initiation of AEDs. Specifically, they find the previous threshold of ≥60% or greater chance of seizure recurrence after a first seizure is likely too high, and 30-40% may be more reasonable.
These conclusions are appropriate, considering the decision analysis model parameters – but, of course, by definition they also depend on the validity of these parameters. Then, whether this decision analysis can be applied clinically in the Emergency Department is another question, considering the challenges with regard to determine whether a seizure is truly unprovoked. Regardless, as AEDs evolve, have fewer adverse effects, and reach generic status, more liberal strategies of AED initiation in the Emergency Department may be in our future.
“Antiepileptic drug treatment after an unprovoked first seizure: A decision analysis”
http://n.neurology.org/content/early/2018/09/12/WNL.0000000000006319