Treatment of first seizure in adults: A comprehensive approach integrating 10 key principles

Assessment of a first seizure (FS) presentation requires a comprehensive and systematic approach to address the complexity of this condition and all of the open questions with regards to accurate interpretation of the initial event, necessary diagnostic steps, prognosis and need for antiepileptic drugs (AED). Counseling about key life style issues and safety considerations in daily life are a major component in the first meeting; which should allow enough time to help to create trust in this vulnerable situation. “Treatment” in this review is therefore used in a holistic way and is not restricted to medication only. Pharmacological treatment of a FS aims to restore normal neuronal function and helps to suppress further seizures. Choosing pharmacological intervention must be guided by incorporating all available clinical information, structural–functional relationships, the underlying pathology, which may specifically include a treatable systematic disease, and the individual's requirements and inclination. Pharmacological treatment should always be considered if the index seizure is not the “first seizure” but actually reflects newly diagnosed epilepsy. AED treatment after a FS is also reasonable, if additional functional and structural tests suggest an epileptic process or if comorbid medical conditions exist (e.g. polytrauma, anticoagulation in an elderly patient with prior stroke) in which any further seizure would lead to additional harm. A comprehensive systematic approach incorporating 10 key principles is presented.