Skip to main content

Advertisement

SpringerLink
Log in

Single unprovoked seizures

  • Published:
Current Treatment Options in Neurology Aims and scope Submit manuscript

Opinion statement

Unprovoked seizures are common, affecting approximately 4% of the population by age 80. Only approximately 30% to 40% of patients with a first seizure will have a second unprovoked seizure (ie, epilepsy). Treatment with antiepileptic drugs (AEDs) should not be initiated unless the diagnosis of a seizure is firm. Decisions regarding treatment of single unprovoked seizures must balance seizure recurrence risk, the potential impact of a recurrent seizure, the likelihood of adverse effects of treatment, and patient preference. Risk factors for seizure recurrence include a history of remote neurologic insult, epileptiform abnormalities on electroencephalogram, focal structural lesion on neuroimaging, and family history of epilepsy. Adult patients with these risk factors have a recurrence risk of 60% to 70% and usually should be treated with an AED to prevent seizure recurrence. Without risk factors, the recurrence risk is 20% to 30%, and treatment depends on individual risk-to-benefit ratios and patient preference. Treatment of a first unprovoked seizure is often not necessary in childhood, especially if the seizure is part of a benign self-limited syndrome, such as benign Rolandic epilepsy of childhood. Treatment with an AED reduces the risk of seizure recurrence after a single unprovoked seizure. This must be balanced against the risk of adverse effects of AEDs. Treatment of the first seizure does not appear to affect the long-term prognosis of epilepsy. The choice of an AED should be guided by the seizure type and likely epilepsy syndrome diagnosis. Monotherapy is preferable. Standard AED options include phenytoin, carbamazepine, valproate, and phenobarbital. The newer AED, including gabapentin, lamotrigine, topiramate, oxcarbazepine, levetiracetam, and zonisamide, have good efficacy, favorable pharmacokinetic profiles, and often fewer adverse effects, supporting their use early in treatment. Not all of the newer AEDs are approved for use as monotherapy. Patients with single seizures should be counseled about seizure first aid and general safety measures, including precautions regarding swimming alone, engaging in high-risk activities, driving, possible seizure precipitation by photic stimuli (in generalized epilepsy), sleep deprivation, and alcohol.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Similar content being viewed by others

References and Recommended Reading

  1. Temkin NR: Antiepileptogenesis and seizure prevention trials with antiepileptic drugs: meta-analysis of controlled trials. Epilepsia 2001, 42:515–524. This is a thorough review of failure of prophylactic AEDs to prevent epilepsy after acute brain injuries or acute symptomatic seizures.

    Article  PubMed  CAS  Google Scholar 

  2. Hauser WA, Anderson VE, Loewenson RB, McRoberts SM: Seizure recurrence after a first unprovoked seizure. N Engl J Med 1982, 307:522–528.

    Article  PubMed  CAS  Google Scholar 

  3. Annegers JF, Shirts SB, Hauser WA, Kurland LT: Risk of recurrence after an initial unprovoked seizure. Epilepsia 1986, 27:43–50.

    PubMed  CAS  Google Scholar 

  4. Hart RG, Easton JD: Seizure recurrence after a first, unprovoked seizure. Arch Neurol 1986, 43:1289–1290.

    PubMed  CAS  Google Scholar 

  5. Hauser WA, Rich SS, Annegers JF, Anderson VE: Seizure recurrence after a 1st unprovoked seizure: an extended follow-up. Neurology 1990, 40:1163–1170.

    PubMed  CAS  Google Scholar 

  6. Shinnar S, Berg AT, Moshe SL, et al.: Risk of seizure recurrence following a first unprovoked seizure in childhood: a prospective study. Pediatrics 1990, 85:1076–1085.

    PubMed  CAS  Google Scholar 

  7. van Donselaar CA, Habbema JD: Recurrence after first seizure. Lancet 1991, 337:46.

    Article  PubMed  Google Scholar 

  8. Bora I, Seckin B, Zarifoglu M, et al.: Risk of recurrence after first unprovoked tonic-clonic seizure in adults. J Neurol 1995, 242:157–163.

    Article  PubMed  CAS  Google Scholar 

  9. Shinnar S, Berg AT, Moshe SL, et al.: The risk of seizure recurrence after a first unprovoked afebrile seizure in childhood: an extended follow-up. Pediatrics 1996, 98:216–225.

    PubMed  CAS  Google Scholar 

  10. Martinovic Z, Jovic N: Seizure recurrence after a first generalized tonic-clonic seizure, in children, adolescents and young adults. Seizure 1997, 6:461–465.

    Article  PubMed  CAS  Google Scholar 

  11. Lindsten H, Stenlund H, Forsgren L: Seizure recurrence in adults after a newly diagnosed unprovoked epileptic seizure. Acta Neurol Scand 2001, 104:202–207.

    Article  PubMed  CAS  Google Scholar 

  12. Berg AT, Shinnar S: The risk of seizure recurrence following a first unprovoked seizure: a quantitative review. Neurology 1991, 41:965–972.

    PubMed  CAS  Google Scholar 

  13. Haltiner AM, Temkin NR, Dikmen SS: Risk of seizure recurrence after the first late posttraumatic seizure. Arch Phys Med Rehabil 1997, 78:835–840.

    Article  PubMed  CAS  Google Scholar 

  14. Sander JW, Hart YM, Johnson AL, Shorvon SD: National General Practice Study of Epilepsy: newly diagnosed epileptic seizures in a general population. Lancet 1990, 336:1267–1271.

    Article  PubMed  CAS  Google Scholar 

  15. Forsgren L, Bucht G, Eriksson S, Bergmark L: Incidence and clinical characterization of unprovoked seizures in adults: a prospective population-based study. Epilepsia 1996, 37:224–229.

    Article  PubMed  CAS  Google Scholar 

  16. Jallon P, Loiseau P, Loiseau J: Newly diagnosed unprovoked epileptic seizures: presentation at diagnosis in CAROLE study. Coordination Active du Reseau Observatoire Longitudinal de l’ Epilepsie. Epilepsia 2001, 42:464–475.

    Article  PubMed  CAS  Google Scholar 

  17. Hauser WA, Rich SS, Lee JR, et al.: Risk of recurrent seizures after two unprovoked seizures. N Engl J Med 1998, 338:429–434.

    Article  PubMed  CAS  Google Scholar 

  18. Shinnar S, Berg AT, O’Dell C, et al.: 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.

    Article  PubMed  CAS  Google Scholar 

  19. Kirby S, Sadler RM: Injury and death as a result of seizures. Epilepsia 1995, 36:25–28.

    Article  PubMed  CAS  Google Scholar 

  20. Olafsson E, Hauser WA, Gudmundsson G: Long-term survival of people with unprovoked seizures: a population-based study. Epilepsia 1998, 39:89–92.

    Article  PubMed  CAS  Google Scholar 

  21. DeLorenzo RJ, Hauser WA, Towne AR, et al.: A prospective, population-based epidemiologic study of status epilepticus in Richmond, Virginia. Neurology 1996, 46:1029–1035.

    PubMed  CAS  Google Scholar 

  22. Sutula TP, Hagen J, Pitkanen A: Do epileptic seizures damage the brain? Curr Opin Neurol 2003, 16:189–195.

    Article  PubMed  Google Scholar 

  23. Randomized clinical trial on the efficacy of antiepileptic drugs in reducing the risk of relapse after a first unprovoked tonic-clonic seizure. First Seizure Trial Group (FIR.S.T. Group). Neurology 1993, 43:478–483.

  24. Camfield P, Camfield C, Dooley J, et al.: A randomized study of carbamazepine versus no medication after a first unprovoked seizure in childhood. Neurology 1989, 39:851–852.

    PubMed  CAS  Google Scholar 

  25. Gilad R, Lampl Y, Gabbay U, et al.: Early treatment of a single generalized tonic-clonic seizure to prevent recurrence. Arch Neurol 1996, 53:1149–1152.

    PubMed  CAS  Google Scholar 

  26. Musicco M, Beghi E, Solari A, Viani F: Treatment of first tonic-clonic seizure does not improve the prognosis of epilepsy. First Seizure Trial Group (FIRST Group). Neurology 1997, 49:991–998.

    PubMed  CAS  Google Scholar 

  27. Camfield P, Camfield C, Smith S, et al.: Long-term outcome is unchanged by antiepileptic drug treatment after a first seizure: a 15-year follow-up from a randomized trial in childhood. Epilepsia 2002, 43:662–663.

    Article  PubMed  Google Scholar 

  28. Berg AT, Shinnar S: Relapse following discontinuation of antiepileptic drugs: a meta-analysis. Neurology 1994, 44:601–608.

    PubMed  CAS  Google Scholar 

  29. Arroyo S, de la Morena A: Life-threatening adverse events of antiepileptic drugs. Epilepsy Res 2001, 47:155–174. A thorough review of idiosyncratic reactions to AEDs and limitations of current surveillance methods.

    Article  PubMed  CAS  Google Scholar 

  30. Adverse reactions to antiepileptic drugs: a multicenter survey of clinical practice. Collaborative Group for Epidemiology of Epilepsy. Epilepsia 1986, 27:323–330.

  31. Gil-Nagel A: Review of new antiepileptic drugs as initial therapy. Epilepsia 2003, 44(suppl):3–10. An excellent review of completed monotherapy trials of AEDs.

    Article  PubMed  CAS  Google Scholar 

  32. Zahn CA, Morrell MJ, Collins SD, et al.: Management issues for women with epilepsy: a review of the literature. Neurology 1998, 51:949-956. 33. Pack AM, Morrell MJ: Treatment of women with epilepsy. Semin Neurol 2002, 22:289–298.

    Article  Google Scholar 

  33. Pennell PB: Pregnancy in the woman with epilepsy: maternal and fetal outcomes. Semin Neurol 2002, 22:299–308. This review includes up-to-date review of teratogenicity of available AEDs.

    Article  PubMed  Google Scholar 

  34. King MA, Newton MR, Jackson GD, et al.: Epileptology of the first-seizure presentation: a clinical, electroencephalographic, and magnetic resonance imaging study of 300 consecutive patients. Lancet 1998, 352:1007–1011.

    Article  PubMed  CAS  Google Scholar 

  35. Ng SK, Hauser WA, Brust JC, Susser M: Alcohol consumption and withdrawal in new-onset seizures. N Engl J Med 1988, 319:666–673.

    Article  PubMed  CAS  Google Scholar 

  36. Ng SK, Brust JC, Hauser WA, Susser M: Illicit drug use and the risk of new-onset seizures. Am J Epidemiol 1990, 132:47–57.

    PubMed  CAS  Google Scholar 

  37. Kwan P, Brodie MJ: Effectiveness of first antiepileptic drug. Epilepsia 2001, 42:1255–1260. Examines outcomes of treatment of a cohort of patients with newly diagnosed epilepsy, demonstrating that 60% of patients will achieve seizure freedom with a single AED, and that failure to respond to a first drug usually indicates intractability.

    Article  PubMed  CAS  Google Scholar 

  38. Mattson RH, Cramer JA, Collins JF, et al.: Comparison of carbamazepine, phenobarbital, phenytoin, and primidone in partial and secondarily generalized tonic-clonic seizures. N Engl J Med 1985, 313:145–151.

    Article  PubMed  CAS  Google Scholar 

  39. Heller AJ, Chesterman P, Elwes RD, et al.: Phenobarbitone, phenytoin, carbamazepine, or sodium valproate for newly diagnosed adult epilepsy: a randomized comparative monotherapy trial. J Neurol Neurosurg Psychiatry 1995, 58:44–50.

    PubMed  CAS  Google Scholar 

  40. Mattson RH, Cramer JA, Collins JF: A comparison of valproate with carbamazepine for the treatment of complex partial seizures and secondarily generalized tonic-clonic seizures in adults. The Department of Veterans Affairs Epilepsy Cooperative Study No. 264 Group. N Engl J Med 1992, 327:765–771.

    Article  PubMed  CAS  Google Scholar 

  41. Richens A, Davidson DL, Cartlidge NE, Easter DJ: A multicenter comparative trial of sodium valproate and carbamazepine in adult onset epilepsy. Adult EPITEG Collaborative Group. J Neurol Neurosurg Psychiatry 1994, 57:682–687.

    Article  PubMed  CAS  Google Scholar 

  42. Steiner TJ, Dellaportas CI, Findley LJ, et al.: Lamotrigine monotherapy in newly diagnosed untreated epilepsy: a double-blind comparison with phenytoin. Epilepsia 1999, 40:601–607.

    PubMed  CAS  Google Scholar 

  43. Brodie MJ, Richens A, Yuen AW: Double-blind comparison of lamotrigine and carbamazepine in newly diagnosed epilepsy. UK Lamotrigine/Carbamazepine Monotherapy Trial Group. Lancet 1995, 345:476–479.

    Article  PubMed  CAS  Google Scholar 

  44. Christe W, Kramer G, Vigonius U, et al.: A double-blind controlled clinical trial: oxcarbazepine versus sodium valproate in adults with newly diagnosed epilepsy. Epilepsy Res 1997, 26:451–460.

    Article  PubMed  CAS  Google Scholar 

  45. Bill PA, Vigonius U, Pohlmann H, et al.: A double-blind controlled clinical trial of oxcarbazepine versus phenytoin in adults with previously untreated epilepsy. Epilepsy Res 1997, 27:195–204.

    Article  PubMed  CAS  Google Scholar 

  46. Dam M, Ekberg R, Loyning Y, et al.: A double-blind study comparing oxcarbazepine and carbamazepine in patients with newly diagnosed, previously untreated epilepsy. Epilepsy Res 1989, 3:70–76.

    Article  PubMed  CAS  Google Scholar 

  47. Chadwick DW, Anhut H, Greiner MJ, et al.: A doubleblind trial of gabapentin monotherapy for newly diagnosed partial seizures. International Gabapentin Monotherapy Study Group 945-77. Neurology 1998, 51:1282–1288.

    PubMed  CAS  Google Scholar 

  48. Brodie MJ, Chadwick DW, Anhut H, et al.: Gabapentin versus lamotrigine monotherapy: a double-blind comparison in newly diagnosed epilepsy. Epilepsia 2002, 43:993–1000.

    Article  PubMed  CAS  Google Scholar 

  49. Gilliam FG, Veloso F, Bomhof MA, et al.: A dosecomparison trial of topiramate as monotherapy in recently diagnosed partial epilepsy. Neurology 2003, 60:196–202.

    PubMed  CAS  Google Scholar 

  50. Privitera MD, Brodie MJ, Mattson RH, et al.: Topiramate, carbamazepine and valproate monotherapy: double-blind comparison in newly diagnosed epilepsy. Acta Neurol Scand 2003, 107:165–175.

    Article  PubMed  CAS  Google Scholar 

  51. Schachter SC: Tiagabine monotherapy in the treatment of partial epilepsy. Epilepsia 1995, 36(suppl):2–6.

    Article  Google Scholar 

  52. Alsaadi TM, Thieman C: Levetiracetam monotherapy for newly diagnosed epilepsy patients. Seizure 2003, 12:154–156.

    Article  PubMed  Google Scholar 

  53. Drug prices and information. http://www.drugstore.com.

  54. Tennis P, Eldridge RR: Preliminary results on pregnancy outcomes in women using lamotrigine. Epilepsia 2002, 43:1161–1167.

    Article  PubMed  CAS  Google Scholar 

  55. Shorvon SD, Lowenthal A, Janz D, et al.: Multicenter double-blind, randomized, placebo-controlled trial of levetiracetam as add-on therapy in patients with refractory partial seizures. European Levetiracetam Study Group. Epilepsia 2000, 41:1179–1186.

    Article  PubMed  CAS  Google Scholar 

  56. Levine M, McCollom R, Chang T, Orr J: Evaluation of serum phenytoin monitoring in an acute care setting. Ther Drug Monit 1988, 10:50–57.

    PubMed  CAS  Google Scholar 

  57. Faught E, Wilder BJ, Ramsay RE, et al.: Topiramate placebo-controlled dose-ranging trial in refractory partial epilepsy using 200-, 400-, and 600-mg daily dosages. Topiramate YD Study Group. Neurology 1996, 46:1684–1690.

    PubMed  CAS  Google Scholar 

  58. Thibault M, Blume WT, Saint-Hilaire JM, et al.: Divalproex extended-release versus the original divalproex tablet: results of a randomized, crossover study of well-controlled epileptic patients with primary generalized seizures. Epilepsy Res 2002, 50:243–249.

    Article  PubMed  CAS  Google Scholar 

  59. 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. An evidence-based review of therapy options after a first unprovoked seizure in childhood.

    Article  PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Penn Epilepsy Center, Department of Neurology, Hospital of the University of Pennsylvania, 3400 Spruce Street, 3 West Gates, 19104, Philadelphia, PA, USA

    Susan T. Herman MD

Authors
  1. Susan T. Herman MD
    View author publications

    You can also search for this author in PubMed Google Scholar

Rights and permissions

Reprints and permissions

About this article

Cite this article

Herman, S.T. Single unprovoked seizures. Curr Treat Options Neurol 6, 243–255 (2004). https://doi.org/10.1007/s11940-004-0016-5

Download citation

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11940-004-0016-5

Keywords

Search

Navigation