title: Evidence-based guideline: Management of an unprovoked first seizure in adults: Report of the Guideline Development Subcommittee of the American Academy of Neurology and the American Epilepsy Society.
abstract: OBJECTIVE
  To provide evidence-based recommendations for treatment of adults with an unprovoked first seizure.
  
  
  METHODS
  We defined relevant questions and systematically reviewed published studies according to the American Academy of Neurology's classification of evidence criteria; we based recommendations on evidence level.
  
  
  CONCLUSIONS
  Adults with an unprovoked first seizure should be informed that their seizure recurrence risk is greatest early within the first 2 years (21%-45%) (Level A), and clinical variables associated with increased risk may include a prior brain insult (Level A), an EEG with epileptiform abnormalities (Level A), a significant brain-imaging abnormality (Level B), and a nocturnal seizure (Level B). Immediate antiepileptic drug (AED) therapy, as compared with delay of treatment pending a second seizure, is likely to reduce recurrence risk within the first 2 years (Level B) but may not improve quality of life (Level C). Over a longer term (>3 years), immediate AED treatment is unlikely to improve prognosis as measured by sustained seizure remission (Level B). Patients should be advised that risk of AED adverse events (AEs) may range from 7% to 31% (Level B) and that these AEs are likely predominantly mild and reversible. Clinicians' recommendations whether to initiate immediate AED treatment after a first seizure should be based on individualized assessments that weigh the risk of recurrence against the AEs of AED therapy, consider educated patient preferences, and advise that immediate treatment will not improve the long-term prognosis for seizure remission but will reduce seizure risk over the subsequent 2 years.
authors.affiliation: From the Department of Neurology, Maryland Epilepsy Center (A.K.), and Department of Neurology (A.M.S., A.A.K., J.P.M., J.L.H.), University of Maryland School of Medicine, Baltimore; US Department of Veterans Affairs (A.K.), Maryland Healthcare System, Epilepsy Center of Excellence, Baltimore, MD; Department of Clinical Neuroscience (S.W.), University of Calgary Faculty of Medicine, Canada; Department of Neurology (G.S.G.), University of Kansas School of Medicine, Kansas City, KS; Department of Neurology (D.S.G.), Geisinger Health System, Danville, PA; Department of Emergency Medicine (A.T.L.), George Washington University School of Medicine, Washington, DC; Department of Neurology (A.M.K.), International Center for Epilepsy, University of Miami Miller School of Medicine, FL; Departments of Neurology, Pediatrics, and Epidemiology & Population Health (S.S.), Albert Einstein College of Medicine, Yeshiva University, Bronx; and New York University Comprehensive Epilepsy Center (J.A.F.), New York, NY.
authors.forename: Allan
authors.initials: A
authors.lastname: Krumholz
authors.affiliation: From the Department of Neurology, Maryland Epilepsy Center (A.K.), and Department of Neurology (A.M.S., A.A.K., J.P.M., J.L.H.), University of Maryland School of Medicine, Baltimore; US Department of Veterans Affairs (A.K.), Maryland Healthcare System, Epilepsy Center of Excellence, Baltimore, MD; Department of Clinical Neuroscience (S.W.), University of Calgary Faculty of Medicine, Canada; Department of Neurology (G.S.G.), University of Kansas School of Medicine, Kansas City, KS; Department of Neurology (D.S.G.), Geisinger Health System, Danville, PA; Department of Emergency Medicine (A.T.L.), George Washington University School of Medicine, Washington, DC; Department of Neurology (A.M.K.), International Center for Epilepsy, University of Miami Miller School of Medicine, FL; Departments of Neurology, Pediatrics, and Epidemiology & Population Health (S.S.), Albert Einstein College of Medicine, Yeshiva University, Bronx; and New York University Comprehensive Epilepsy Center (J.A.F.), New York, NY.
authors.forename: Samuel
authors.initials: S
authors.lastname: Wiebe
authors.affiliation: From the Department of Neurology, Maryland Epilepsy Center (A.K.), and Department of Neurology (A.M.S., A.A.K., J.P.M., J.L.H.), University of Maryland School of Medicine, Baltimore; US Department of Veterans Affairs (A.K.), Maryland Healthcare System, Epilepsy Center of Excellence, Baltimore, MD; Department of Clinical Neuroscience (S.W.), University of Calgary Faculty of Medicine, Canada; Department of Neurology (G.S.G.), University of Kansas School of Medicine, Kansas City, KS; Department of Neurology (D.S.G.), Geisinger Health System, Danville, PA; Department of Emergency Medicine (A.T.L.), George Washington University School of Medicine, Washington, DC; Department of Neurology (A.M.K.), International Center for Epilepsy, University of Miami Miller School of Medicine, FL; Departments of Neurology, Pediatrics, and Epidemiology & Population Health (S.S.), Albert Einstein College of Medicine, Yeshiva University, Bronx; and New York University Comprehensive Epilepsy Center (J.A.F.), New York, NY.
authors.forename: Gary S
authors.initials: GS
authors.lastname: Gronseth
authors.affiliation: From the Department of Neurology, Maryland Epilepsy Center (A.K.), and Department of Neurology (A.M.S., A.A.K., J.P.M., J.L.H.), University of Maryland School of Medicine, Baltimore; US Department of Veterans Affairs (A.K.), Maryland Healthcare System, Epilepsy Center of Excellence, Baltimore, MD; Department of Clinical Neuroscience (S.W.), University of Calgary Faculty of Medicine, Canada; Department of Neurology (G.S.G.), University of Kansas School of Medicine, Kansas City, KS; Department of Neurology (D.S.G.), Geisinger Health System, Danville, PA; Department of Emergency Medicine (A.T.L.), George Washington University School of Medicine, Washington, DC; Department of Neurology (A.M.K.), International Center for Epilepsy, University of Miami Miller School of Medicine, FL; Departments of Neurology, Pediatrics, and Epidemiology & Population Health (S.S.), Albert Einstein College of Medicine, Yeshiva University, Bronx; and New York University Comprehensive Epilepsy Center (J.A.F.), New York, NY.
authors.forename: David S
authors.initials: DS
authors.lastname: Gloss
authors.affiliation: From the Department of Neurology, Maryland Epilepsy Center (A.K.), and Department of Neurology (A.M.S., A.A.K., J.P.M., J.L.H.), University of Maryland School of Medicine, Baltimore; US Department of Veterans Affairs (A.K.), Maryland Healthcare System, Epilepsy Center of Excellence, Baltimore, MD; Department of Clinical Neuroscience (S.W.), University of Calgary Faculty of Medicine, Canada; Department of Neurology (G.S.G.), University of Kansas School of Medicine, Kansas City, KS; Department of Neurology (D.S.G.), Geisinger Health System, Danville, PA; Department of Emergency Medicine (A.T.L.), George Washington University School of Medicine, Washington, DC; Department of Neurology (A.M.K.), International Center for Epilepsy, University of Miami Miller School of Medicine, FL; Departments of Neurology, Pediatrics, and Epidemiology & Population Health (S.S.), Albert Einstein College of Medicine, Yeshiva University, Bronx; and New York University Comprehensive Epilepsy Center (J.A.F.), New York, NY.
authors.forename: Ana M
authors.initials: AM
authors.lastname: Sanchez
authors.affiliation: From the Department of Neurology, Maryland Epilepsy Center (A.K.), and Department of Neurology (A.M.S., A.A.K., J.P.M., J.L.H.), University of Maryland School of Medicine, Baltimore; US Department of Veterans Affairs (A.K.), Maryland Healthcare System, Epilepsy Center of Excellence, Baltimore, MD; Department of Clinical Neuroscience (S.W.), University of Calgary Faculty of Medicine, Canada; Department of Neurology (G.S.G.), University of Kansas School of Medicine, Kansas City, KS; Department of Neurology (D.S.G.), Geisinger Health System, Danville, PA; Department of Emergency Medicine (A.T.L.), George Washington University School of Medicine, Washington, DC; Department of Neurology (A.M.K.), International Center for Epilepsy, University of Miami Miller School of Medicine, FL; Departments of Neurology, Pediatrics, and Epidemiology & Population Health (S.S.), Albert Einstein College of Medicine, Yeshiva University, Bronx; and New York University Comprehensive Epilepsy Center (J.A.F.), New York, NY.
authors.forename: Arif A
authors.initials: AA
authors.lastname: Kabir
authors.affiliation: From the Department of Neurology, Maryland Epilepsy Center (A.K.), and Department of Neurology (A.M.S., A.A.K., J.P.M., J.L.H.), University of Maryland School of Medicine, Baltimore; US Department of Veterans Affairs (A.K.), Maryland Healthcare System, Epilepsy Center of Excellence, Baltimore, MD; Department of Clinical Neuroscience (S.W.), University of Calgary Faculty of Medicine, Canada; Department of Neurology (G.S.G.), University of Kansas School of Medicine, Kansas City, KS; Department of Neurology (D.S.G.), Geisinger Health System, Danville, PA; Department of Emergency Medicine (A.T.L.), George Washington University School of Medicine, Washington, DC; Department of Neurology (A.M.K.), International Center for Epilepsy, University of Miami Miller School of Medicine, FL; Departments of Neurology, Pediatrics, and Epidemiology & Population Health (S.S.), Albert Einstein College of Medicine, Yeshiva University, Bronx; and New York University Comprehensive Epilepsy Center (J.A.F.), New York, NY.
authors.forename: Aisha T
authors.initials: AT
authors.lastname: Liferidge
authors.affiliation: From the Department of Neurology, Maryland Epilepsy Center (A.K.), and Department of Neurology (A.M.S., A.A.K., J.P.M., J.L.H.), University of Maryland School of Medicine, Baltimore; US Department of Veterans Affairs (A.K.), Maryland Healthcare System, Epilepsy Center of Excellence, Baltimore, MD; Department of Clinical Neuroscience (S.W.), University of Calgary Faculty of Medicine, Canada; Department of Neurology (G.S.G.), University of Kansas School of Medicine, Kansas City, KS; Department of Neurology (D.S.G.), Geisinger Health System, Danville, PA; Department of Emergency Medicine (A.T.L.), George Washington University School of Medicine, Washington, DC; Department of Neurology (A.M.K.), International Center for Epilepsy, University of Miami Miller School of Medicine, FL; Departments of Neurology, Pediatrics, and Epidemiology & Population Health (S.S.), Albert Einstein College of Medicine, Yeshiva University, Bronx; and New York University Comprehensive Epilepsy Center (J.A.F.), New York, NY.
authors.forename: Justin P
authors.initials: JP
authors.lastname: Martello
authors.affiliation: From the Department of Neurology, Maryland Epilepsy Center (A.K.), and Department of Neurology (A.M.S., A.A.K., J.P.M., J.L.H.), University of Maryland School of Medicine, Baltimore; US Department of Veterans Affairs (A.K.), Maryland Healthcare System, Epilepsy Center of Excellence, Baltimore, MD; Department of Clinical Neuroscience (S.W.), University of Calgary Faculty of Medicine, Canada; Department of Neurology (G.S.G.), University of Kansas School of Medicine, Kansas City, KS; Department of Neurology (D.S.G.), Geisinger Health System, Danville, PA; Department of Emergency Medicine (A.T.L.), George Washington University School of Medicine, Washington, DC; Department of Neurology (A.M.K.), International Center for Epilepsy, University of Miami Miller School of Medicine, FL; Departments of Neurology, Pediatrics, and Epidemiology & Population Health (S.S.), Albert Einstein College of Medicine, Yeshiva University, Bronx; and New York University Comprehensive Epilepsy Center (J.A.F.), New York, NY.
authors.forename: Andres M
authors.initials: AM
authors.lastname: Kanner
authors.affiliation: From the Department of Neurology, Maryland Epilepsy Center (A.K.), and Department of Neurology (A.M.S., A.A.K., J.P.M., J.L.H.), University of Maryland School of Medicine, Baltimore; US Department of Veterans Affairs (A.K.), Maryland Healthcare System, Epilepsy Center of Excellence, Baltimore, MD; Department of Clinical Neuroscience (S.W.), University of Calgary Faculty of Medicine, Canada; Department of Neurology (G.S.G.), University of Kansas School of Medicine, Kansas City, KS; Department of Neurology (D.S.G.), Geisinger Health System, Danville, PA; Department of Emergency Medicine (A.T.L.), George Washington University School of Medicine, Washington, DC; Department of Neurology (A.M.K.), International Center for Epilepsy, University of Miami Miller School of Medicine, FL; Departments of Neurology, Pediatrics, and Epidemiology & Population Health (S.S.), Albert Einstein College of Medicine, Yeshiva University, Bronx; and New York University Comprehensive Epilepsy Center (J.A.F.), New York, NY.
authors.forename: Shlomo
authors.initials: S
authors.lastname: Shinnar
authors.affiliation: From the Department of Neurology, Maryland Epilepsy Center (A.K.), and Department of Neurology (A.M.S., A.A.K., J.P.M., J.L.H.), University of Maryland School of Medicine, Baltimore; US Department of Veterans Affairs (A.K.), Maryland Healthcare System, Epilepsy Center of Excellence, Baltimore, MD; Department of Clinical Neuroscience (S.W.), University of Calgary Faculty of Medicine, Canada; Department of Neurology (G.S.G.), University of Kansas School of Medicine, Kansas City, KS; Department of Neurology (D.S.G.), Geisinger Health System, Danville, PA; Department of Emergency Medicine (A.T.L.), George Washington University School of Medicine, Washington, DC; Department of Neurology (A.M.K.), International Center for Epilepsy, University of Miami Miller School of Medicine, FL; Departments of Neurology, Pediatrics, and Epidemiology & Population Health (S.S.), Albert Einstein College of Medicine, Yeshiva University, Bronx; and New York University Comprehensive Epilepsy Center (J.A.F.), New York, NY.
authors.forename: Jennifer L
authors.initials: JL
authors.lastname: Hopp
authors.affiliation: From the Department of Neurology, Maryland Epilepsy Center (A.K.), and Department of Neurology (A.M.S., A.A.K., J.P.M., J.L.H.), University of Maryland School of Medicine, Baltimore; US Department of Veterans Affairs (A.K.), Maryland Healthcare System, Epilepsy Center of Excellence, Baltimore, MD; Department of Clinical Neuroscience (S.W.), University of Calgary Faculty of Medicine, Canada; Department of Neurology (G.S.G.), University of Kansas School of Medicine, Kansas City, KS; Department of Neurology (D.S.G.), Geisinger Health System, Danville, PA; Department of Emergency Medicine (A.T.L.), George Washington University School of Medicine, Washington, DC; Department of Neurology (A.M.K.), International Center for Epilepsy, University of Miami Miller School of Medicine, FL; Departments of Neurology, Pediatrics, and Epidemiology & Population Health (S.S.), Albert Einstein College of Medicine, Yeshiva University, Bronx; and New York University Comprehensive Epilepsy Center (J.A.F.), New York, NY.
authors.forename: Jacqueline A
authors.initials: JA
authors.lastname: French
mesh_terms: D000328:Adult; D000927:Anticonvulsants / Q000009:adverse effects / Q000627:therapeutic use*; D019317:Evidence-Based Medicine / Q000592:standards*; D006801:Humans; D017410:Practice Guidelines as Topic / Q000592:standards*; D012306:Risk; D012640:Seizures / Q000188:drug therapy / Q000628:therapy*; D012955:Societies, Medical / Q000592:standards*
chemical_list: D000927:Anticonvulsants