Advertisement

CNS Drugs

, Volume 21, Issue 2, pp 89–99 | Cite as

Treatment Strategies After a Single Seizure

Rationale for Immediate versus Deferred Treatment
  • Laura C. Miller
  • Frank W. Drislane
Leading Article

Abstract

What is the rationale for the treatment of an epileptic seizure? More specifically, should a first seizure be treated as soon as it is diagnosed or should one defer treatment until a second seizure occurs? Several studies indicate that the risk of a second (unprovoked) seizure is <50%, but studies vary in methodology and most have reviewed outcome in children only. Also, many patients were maintained on antiepileptic drugs (AEDs) during these studies, meaning that the risk for seizure recurrence was perhaps underestimated compared with the risk if untreated.

Most neurologists recommend waiting for a second seizure in order to avoid complications of medications that might prove to be unnecessary. Several large studies show that delaying treatment until a second seizure occurs does not worsen the course of epilepsy or likelihood of eventual seizure control. Seizures attributable to an acute illness (‘acute symptomatic’, provoked seizures) usually resolve with treatment of the underlying illness and thus long-term AEDs are often unwarranted. Nevertheless, seizures arising in certain circumstances are more likely to recur and there are special considerations for patients with strokes, tumours, infections and dementia, and also after head injury or neurosurgery.

Patient preferences with regard to risk and benefit also enter into the decision on whether to initiate AED treatment after a single seizure.

Keywords

Epileptic Seizure Seizure Recurrence Unprovoked Seizure Early Seizure International League Against Epilepsy 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Notes

Acknowledgements

No sources of funding were used to assist in the preparation of this review. The authors have no conflicts of interest that are directly relevant to the content of this review.

References

  1. 1.
    Hauser WA. Should people be treated after a first seizure? Arch Neurology 1986; 43: 1287–8CrossRefGoogle Scholar
  2. 2.
    Elwes RDC, Reynolds EH. Should people be treated after a first seizure? Arch Neurology 1988; 45: 490–1CrossRefGoogle Scholar
  3. 3.
    Commission on Epidemiology and Prognosis, International League Against Epilepsy. Guidelines for epidemiologic studies on epilepsy. Epilepsia 1993; 34: 592–6CrossRefGoogle Scholar
  4. 4.
    Scheepers B, Clough P, Pickles C. The misdiagnosis of epilepsy: findings of a population study. Seizure 1998; 7: 403–6PubMedCrossRefGoogle Scholar
  5. 5.
    Smith D, Defalla BA, Chadwick DW. The misdiagnosis of epilepsy and the management of refractory epilepsy in a specialist clinic. QJM 1999; 92: 15–23PubMedCrossRefGoogle Scholar
  6. 6.
    Van Donselaar CA, Geerts AT, Habbema JDF, et al. Reliability of the diagnosis of a first seizure. Neurology 1989; 39: 267–71PubMedCrossRefGoogle Scholar
  7. 7.
    Jallon P, Loiseau P, Loiseau J. Newly diagnosed unprovoked epileptic seizures: presentation at diagnosis in CAROLE study. Epilepsia 2001; 42: 464–75PubMedCrossRefGoogle Scholar
  8. 8.
    Hauser WA, Anderson VE, Loewenson RB, et al. Seizure recurrence after a first unprovoked seizure. N Engl J Med 1982; 307: 522–8PubMedCrossRefGoogle Scholar
  9. 9.
    Elwes RDC, Chesterman P, Reynolds EH. Prognosis after a first untreated tonic-clonic seizure. Lancet 1985; II: 752–3CrossRefGoogle Scholar
  10. 10.
    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: 216–25PubMedGoogle Scholar
  11. 11.
    Stroink A, Brouwer OF, Arts WF, et al. The first unprovoked, untreated seizure in childhood: a hospital based study of the accuracy of the diagnosis, rate of recurrence, and long term outcome after recurrence. Dutch Study of Epilepsy in Childhood. J Neurol Neurosurg Psychiatry 1998; 64: 595–600Google Scholar
  12. 12.
    Berg AT, Shinnar S. The risk of seizure recurrence following a first unprovoked seizure: a quantitative review. Neurology 1991; 41: 965–72PubMedCrossRefGoogle Scholar
  13. 13.
    Hauser WA, Rich SS, Lee JRJ, et al. Risk of recurrent seizures after two unprovoked seizures. N Engl J Med 1998; 338: 429–34PubMedCrossRefGoogle Scholar
  14. 14.
    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: 140–7PubMedCrossRefGoogle Scholar
  15. 15.
    Gilad R, Lampl Y, Gabbay U, et al. Early treatment of a single generalized tonic-clonic seizure to prevent recurrence. Arch Neurol 1996; 53: 1149–52PubMedCrossRefGoogle Scholar
  16. 16.
    First Seizure Trial Group. Randomized clinical trial on the efficacy of antiepileptic drugs in reducing the risk of relapse after a first unprovoked tonic-clonic seizure. Neurology 1993; 3: 478–83Google Scholar
  17. 17.
    Musicco M, Beghi E, Solari A, et al. Treatment of first tonic-clonic seizure does not improve the prognosis of epilepsy. Neurology 1997; 49: 991–8PubMedCrossRefGoogle Scholar
  18. 18.
    Marson A, Jacoby A, Johnson A, et al. Immediate versus deferred antiepileptic drug treatment for early epilepsy and single seizures: a randomized controlled trial. Medical Research Council MESS Study Group. Lancet 2005; 365: 2007–13Google Scholar
  19. 19.
    Feksi AT, Kaamugisha J, Sander JWAS, et al. Comprehensive primary health care antiepileptic drug treatment programme in rural and semi-urban Kenya. Lancet 1991; 337: 406–9PubMedCrossRefGoogle Scholar
  20. 20.
    Berg AT, Shinnar S. Do seizures beget seizures? An assessment of the clinical evidence in humans. J Clin Neurophysiol 1997; 14: 102–10PubMedCrossRefGoogle Scholar
  21. 21.
    MacDonald BK, Johnson AL, Goodridge DM, et al. Factors predicting prognosis of epilepsy after presentation with seizures. Ann Neurol 2000; 48: 833–41PubMedCrossRefGoogle Scholar
  22. 22.
    Kaplan PW. Reproductive health effects and teratogenicity of antiepileptic drugs. Neurology 2004; 63Suppl. 4: S13–23PubMedCrossRefGoogle Scholar
  23. 23.
    Kilpatrick CJ, Davis SM, Tress BM, et al. Epileptic seizures in acute stroke. Arch Neurol 1990; 47: 157–60PubMedCrossRefGoogle Scholar
  24. 24.
    Giroud M, Gras P, Fayolle H, et al. Early seizures after acute stroke: a study of 1640 cases. Epilepsia 1994; 35: 959–64PubMedCrossRefGoogle Scholar
  25. 25.
    Labovitz DL, Hauser WA, Sacco RL. Prevalence and predictors of early seizure and status epilepticus after first stroke. Neurology 2001; 57: 200–6PubMedCrossRefGoogle Scholar
  26. 26.
    Arboix A, Comes E, Massons J, et al. Relevance of early seizures for in-hospital mortality in acute cerebrovascular disease. Neurology 1996; 47: 1429–35PubMedCrossRefGoogle Scholar
  27. 27.
    Lancman ME, Golimstok A, Norscini J, et al. Risk factors for developing seizures after a stroke. Epilepsia 1993; 34: 141–3PubMedCrossRefGoogle Scholar
  28. 28.
    Olsen TS, Høgenhaven H, Thage O. Epilepsy after stroke. Neurology 1987; 37: 1209–11PubMedCrossRefGoogle Scholar
  29. 29.
    Burn J, Dennis M, Bamford J, et al. Epileptic seizures after a first stroke: the Oxfordshire community stroke project. BMJ 1997; 315: 1582–7PubMedCrossRefGoogle Scholar
  30. 30.
    Sung CY, Chu NS. Epileptic seizures in thrombotic stroke. J Neurol 1990; 237: 166–70PubMedCrossRefGoogle Scholar
  31. 31.
    Bladin CF, Alexandrov AV, Bellavance A, et al. Seizures after stroke. Arch Neurol 2000; 57: 1617–22PubMedCrossRefGoogle Scholar
  32. 32.
    Liigant A, Haldre S, Õun A, et al. Seizure disorders in patients with brain tumors. Eur Neurol 2001; 45: 46–51PubMedCrossRefGoogle Scholar
  33. 33.
    Glantz MJ, Cole BF, Forsyth PA, et al. Practice parameter: anticonvulsant prophylaxis in patients with newly diagnosed brain tumors. Neurology 2000; 54: 1886–93PubMedCrossRefGoogle Scholar
  34. 34.
    Matthew E, Sherwin AL, Welner SA, et al. Seizures following intracranial surgery: incidence in the first post-operative week. Can J Neurosci 1980; 7: 285–90Google Scholar
  35. 35.
    North JB, Penhall RB, Hanieh A, et al. Phenytoin and postoperative epilepsy. J Neurosurg 1983; 58: 672–7PubMedCrossRefGoogle Scholar
  36. 36.
    Temkin NR. Prophylactic anticonvulsants after neurosurgery. Epilepsy Curr 2002; 2: 105–7PubMedCrossRefGoogle Scholar
  37. 37.
    Manaka S, Ishijima B, Mayanagi Y. Postoperative seizures: epidemiology, pathology, and prophylaxis. Neurol Med Chir (Tokyo) 2003; 43: 589–600CrossRefGoogle Scholar
  38. 38.
    Annegers JF. Epidemiology and genetics of epilepsy. Neurol Clin 1994; 12: 15–29PubMedGoogle Scholar
  39. 39.
    Pomeroy SL, Holmes SJ, Dodge PR, et al. Seizures and other neurologic sequelae of bacterial meningitis in children. N Engl J Med 1990; 323: 1651–7PubMedCrossRefGoogle Scholar
  40. 40.
    Annegers JF, Hauser WA, Beghi E, et al. The risk of unprovoked seizures after encephalitis and meningitis. Neurology 1988; 38: 1407–10PubMedCrossRefGoogle Scholar
  41. 41.
    Monteiro A, Coelho T, Stocker A. Neurocysticercosis-a review of 231 cases. Infection 1992; 20: 61–5PubMedCrossRefGoogle Scholar
  42. 42.
    Carpio A. Neurocysticercosis: an update. Lancet Infect Dis 2002; 2: 751–62PubMedCrossRefGoogle Scholar
  43. 43.
    Carpio A, Hauser WA. Prognosis for seizure recurrence in patients with newly diagnosed neurocysticercosis. Neurology 2002; 59: 1730–4PubMedCrossRefGoogle Scholar
  44. 44.
    Levy RM, Bredesen DE, Rosenblum ML. Neurological manifestations for the acquired immunodeficiency syndrome (AIDS): experience at UCSF and review of the literature. J Neurosurg 1985; 62: 475–95PubMedCrossRefGoogle Scholar
  45. 45.
    Pascual-Sedano B, Iranzo A, Martí-Fàbregas J, et al. Prospective study of new-onset seizures in patients with human immunodeficiency virus infection. Arch Neurol 1999; 56: 609–12PubMedCrossRefGoogle Scholar
  46. 46.
    Modi G, Modi M, Martinus I, et al. New-onset seizures associated with HIV infection. Neurology 2000; 55: 1558–61PubMedCrossRefGoogle Scholar
  47. 47.
    Wong MC, Suite NDA, Labar DR. Seizures in human immunodeficiency virus infection. Arch Neurol 1990; 47: 640–3PubMedCrossRefGoogle Scholar
  48. 48.
    Annegers JF, Gravow JD, Groover RV, et al. Seizures after head trauma: a population based study. Neurology 1980; 30: 683–9PubMedCrossRefGoogle Scholar
  49. 49.
    Annegers JF, Hauser WA, Coan SP, et al. A population-based study of seizures after traumatic brain injuries. N Engl J Med 1998; 338: 20–4PubMedCrossRefGoogle Scholar
  50. 50.
    Angeleri F, Majkowski J, Cacchiò G, et al. Posttraumatic epilepsy risk factors: one-year prospective study after head injury. Epilepsia 1999; 40: 1222–30PubMedCrossRefGoogle Scholar
  51. 51.
    Pohlmann-Eden B, Bruckmeir J. Predictors and dynamics of posttraumatic epilepsy. Acta Neurol Scan 1997; 95: 257–62CrossRefGoogle Scholar
  52. 52.
    Haltiner AM, Temkin NR, Dikmen SS. Risk of seizure recurrence after first late posttraumatic seizure. Arch Phys Med Rehabil 1997; 78: 835–40PubMedCrossRefGoogle Scholar
  53. 53.
    Temkin NR, Dikmen SS, Wilensky AJ, et al. A randomized, double-blind study of phenytoin for the prevention of posttraumatic seizures. N Engl J Med 1990; 323: 497–502PubMedCrossRefGoogle Scholar
  54. 54.
    Schierhout G, Roberts I. Prophylactic antiepileptic agents after head injury: a systematic review. J Neurol Neurosurg Psychiatry 1998; 64: 108–12PubMedCrossRefGoogle Scholar
  55. 55.
    Schierhout G, Roberts I. Anti-epileptic drugs for preventing seizures following acute traumatic brain injury. Cochrane Database Syst Rev 2001; (4): CD 000173Google Scholar
  56. 56.
    Chang BS, Lowenstein DH. Practice parameter: antiepileptic drug prophylaxis in severe traumatic brain injury. Neurology 2003; 60: 10–6PubMedCrossRefGoogle Scholar
  57. 57.
    Mendez MF, Lim GTH. Seizures in elderly patients with dementia. Drugs Aging 2003; 20: 791–803PubMedCrossRefGoogle Scholar
  58. 58.
    Hesdorffer DC, Hauser WA, Annegers JF, et al. Dementia and adult-onset unprovoked seizures. Neurology 1996; 46: 727–30PubMedCrossRefGoogle Scholar
  59. 59.
    Ramsay RE, Pryor F. Epilepsy in the elderly. Neurology 2000; 55Suppl. 1: S9–14PubMedGoogle Scholar
  60. 60.
    Thomas RJ. Seizures and epilepsy in the elderly. Arch Intern Med 1997; 157: 605–17PubMedCrossRefGoogle Scholar
  61. 61.
    Vélez L, Selwa LM. Seizure disorders in the elderly. Am Fam Physician 2003; 67: 323–32Google Scholar
  62. 62.
    Sokić DV, Stojsavljević N, Drulović J, et al. Seizures in multiple sclerosis. Epilepsia 2001; 42: 72–9PubMedGoogle Scholar
  63. 63.
    Kinnunen E, Wikström J. Prevalence and prognosis of epilepsy in patients with multiple sclerosis. Epilepsia 1986; 27: 729–33PubMedCrossRefGoogle Scholar
  64. 64.
    Olafson E, Benedikz J, Hauser WA. Risk of epilepsy in patients with multiple sclerosis: a population-based study in Iceland. pilepsia 1999; 40: 745–7CrossRefGoogle Scholar
  65. 65.
    Nyquist PA, Cascino GD, McClelland RL, et al. Incidence of seizures in patients with multiple sclerosis: a population-based study. Mayo Clin Proc 2002; 77: 910–012PubMedGoogle Scholar

Copyright information

© Adis Data Information BV 2007

Authors and Affiliations

  • Laura C. Miller
    • 1
  • Frank W. Drislane
    • 1
  1. 1.Department of NeurologyBeth Israel Deaconess Medical CenterBostonUSA

Personalised recommendations