Updated October 2025
Adult Seizure Care Pathway
Seizure management in adults: initial evaluation and long-term treatment
Evidence-based approach to adult seizures, integrating initial assessment, risk-stratification, treatment initiation, and long-term management. Highlights AAN/AES guidance for a first unprovoked seizure, workup essentials (EEG, MRI), when to start anti-seizure medications, and counseling on safety and prognosis.
Clinical question
In adults with suspected seizures, how should clinicians perform the initial evaluation and implement long-term treatment strategies, including decisions to initiate anti-seizure medications after a first unprovoked seizure and ongoing management?
NeurologyEmergency MedicineEpilepsyInternal MedicinePrimary Care
Key points
Rapidly distinguish provoked vs unprovoked
Identify reversible precipitants (glucose, Na, Ca, renal/hepatic failure, drugs, alcohol withdrawal) and rule out mimics (syncope, PNES). Provoked events shift management toward treating the cause and often no long-term ASM.
Order EEG and epilepsy-protocol MRI early
EEG within 24–48 hours and high-resolution MRI improve etiologic yield and recurrence risk prediction, guiding ASM initiation decisions.
Shared decision-making on ASM after first unprovoked seizure
Immediate ASM lowers short-term recurrence (absolute reduction ≈ 35%) but does not clearly change long-term remission; weigh risks, lifestyle, and driving.
Safety first: driving and injury prevention
Counsel on driving restrictions per jurisdiction, water/heights precautions, and seizure first-aid for caregivers.
Tailor long-term regimen to syndrome and comorbidities
Select ASM based on seizure type, reproductive plans, drug interactions, and comorbidities; reassess after 2 years seizure-free for taper candidacy.
Evidence highlights
≈ 21–45% overall; higher with EEG/MRI abnormalities
2-year recurrence risk after first unprovoked seizure
Reduces absolute recurrence risk by ≈ 35% within 2 years
Effect of immediate ASM after first seizure
Epilepsy-protocol MRI detects structural etiologies > CT
Imaging yield
Approach to the first suspected seizure in adults
Combine targeted history, exam, and high-yield tests to confirm seizure, classify type, and uncover causes and recurrence risk.
1
Confirm an epileptic event and identify mimics
2
Differentiate provoked vs unprovoked
Check glucose, electrolytes (Na, Ca, Mg), renal/hepatic function, pregnancy test, tox screen as indicated; assess alcohol/benzodiazepine withdrawal and acute structural insults. Treat precipitants promptly; chronic ASM may be unnecessary for purely provoked seizures. [5]
3
Order urgent neuroimaging when indicated
If focal deficits, persistent altered mental status, fever, trauma, anticoagulation, malignancy, or immunosuppression, obtain emergent CT. For most patients, epilepsy-protocol MRI is preferred for etiologic definition. [5]
4
5
Lumbar puncture and additional tests when warranted
Perform LP if fever/meningismus/immunosuppression suggests CNS infection or subarachnoid hemorrhage. Tailor workup to context (autoimmune panels, metabolic tests). [5]
Starting anti-seizure medication (ASM) after a first unprovoked seizure
Balance recurrence risk reduction against adverse effects and patient priorities.
1
2
First-line ASMs by seizure type and key considerations
Choose the simplest effective monotherapy; consider interactions, comorbidities, and reproductive plans.
Focal onset
Preferred: Levetiracetam, Lamotrigine, Lacosamide.
If polypharmacy/CYP interactions a concern: Levetiracetam (minimal interactions).
If mood disorder: Lamotrigine may be beneficial.
Avoid sodium-channel agents if conduction disease or significant hyponatremia risk.
Generalized tonic–clonic (idiopathic generalized epilepsy suspected)
Preferred: Valproate (highest efficacy), alternatives: Levetiracetam, Lamotrigine.
Avoid: Carbamazepine, Oxcarbazepine, Phenytoin in generalized epilepsies (may worsen absence/myoclonus).
In people who can become pregnant: favor Levetiracetam or Lamotrigine over valproate due to teratogenicity.
Absence and myoclonic
Absence: Ethosuximide or Valproate; Lamotrigine as alternative.
Myoclonic: Valproate; alternatives: Levetiracetam, Topiramate.
Avoid narrow-spectrum sodium-channel monotherapies.
Special populations
Pregnancy potential: Avoid Valproate when possible; use Folic acid ≥0.4–4 mg/day; plan preconception.
Older adults: Start low, go slow; prefer Lamotrigine, Levetiracetam; watch hyponatremia with Carbamazepine/Oxcarbazepine.
Renal/hepatic disease: Adjust Levetiracetam for renal function; avoid Valproate in hepatic dysfunction.
Status epilepticus (convulsive) – brief adult algorithm
0–5 min: Stabilize (ABC), check glucose, thiamine/glucose as indicated.
5–10 min: Benzodiazepine: lorazepam IV, diazepam IV, or midazolam IM/IN.
10–30 min: Second-line: fosphenytoin/phenytoin, levetiracetam, or valproate.
>30 min: Refractory: anesthetic infusion (propofol, midazolam) with EEG monitoring; address causes.
Follow-up, counseling, and de-escalation
Proactive counseling reduces harm and improves adherence.
Follow-up and tests
EEG within 24–48 h; consider repeat/sleep-deprived if initial normal but suspicion persists.
Epilepsy-protocol MRI when feasible, even if CT done acutely.
Drug levels when indicated (e.g., phenytoin, valproate); check sodium with carbamazepine/oxcarbazepine.
Screen mood/cognition; address adherence and interactions.
Safety counseling
Driving restrictions per jurisdiction after a first seizure; document counseling.
Water safety: showers over baths; supervised swimming; avoid heights/open flames; use helmets as appropriate.
Sleep hygiene, limit alcohol, avoid triggers (sleep deprivation, missed doses, interacting drugs).
Educate household on seizure first aid; consider rescue med for clusters if recurrent.
Tapering and long-term outcomes
Consider taper after ≥2 years seizure-free with normal exam/EEG and low-risk etiology; taper slowly over months.
Relapse risk post-taper is higher with focal lesions, abnormal EEG, juvenile myoclonic epilepsy, or short seizure-free interval.
Long-term remission likelihood is more related to syndrome/etiology than immediate ASM after the first seizure.
Key elements to document
Clear documentation supports safety, legal requirements, and continuity of care.
1
Seizure description and classification
Onset (focal vs generalized), awareness, motor features, duration, postictal state, and triggers.
2
Risk discussion and shared decision
Record recurrence risk factors, benefits/risks of ASM, patient preferences, and plan for driving/work.
3
Follow-up and alarms
EEG/MRI referrals, lab monitoring plan, return precautions (prolonged seizures, status, injuries), and safety counseling provided.
References
Source material
Primary literature that informs this article.
Management of an Unprovoked First Seizure in Adults
www.uptodate.com
Initial treatment of epilepsy in adults - UpToDate
www.uptodate.com
First seizure presentations in adults: beyond assessment ...
jnnp.bmj.com
Evaluation and management of the first seizure in adults
www.uptodate.com
Evaluation and Management of First-Time Seizure in Adults
pubmed.ncbi.nlm.nih.gov
Management of an unprovoked first seizure in adults ...
pubmed.ncbi.nlm.nih.gov
Management of an Unprovoked First Seizure in Adults ...
pmc.ncbi.nlm.nih.gov
Treatment of status epilepticus in adults: guidelines of the ...
pubmed.ncbi.nlm.nih.gov