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
Elicit eyewitness account: abrupt loss of awareness, tonic–clonic activity, tongue biting (lateral), postictal confusion. Screen for syncope (prodromal lightheadedness, pallor), TIA, migraine aura, and psychogenic nonepileptic seizures. Examine for focal deficits and trauma. [1], [2]
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. [2]
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. [2]
4
Obtain EEG within 24–48 hours
An interictal epileptiform discharge substantially increases recurrence risk and influences ASM decision. Consider sleep-deprived or ambulatory EEG if initial study is normal but suspicion remains high. [2], [3]
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). [2]
Starting anti-seizure medication (ASM) after a first unprovoked seizure
Balance recurrence risk reduction against adverse effects and patient priorities.
1
Estimate recurrence risk
Baseline 2-year recurrence risk ≈ 21–45% after a first unprovoked seizure. Risk is higher with: epileptiform EEG, structural MRI lesion, prior brain insult, or nocturnal seizure. [4], [3]
2
Discuss benefits and limits of immediate ASM
Immediate therapy reduces absolute recurrence by ≈ 35% within 2 years but does not clearly improve long-term remission or quality of life; adverse effects occur in a minority and are usually mild, reversible. Shared decision-making is essential. [4], [3]
3
When to favor starting ASM
Consider ASM when high risk (EEG/MRI abnormalities, neurologic deficit, prior stroke/TBI, strong patient preference, safety-critical occupation, frequent seizures). Deferring ASM is reasonable for low-risk patients with robust safety plans. [4], [3]
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.
First seizure presentations in adults: beyond assessment ...
jnnp.bmj.com
Evaluation and Management of First-Time Seizure in Adults
pubmed.ncbi.nlm.nih.gov
Management of an Unprovoked First Seizure in Adults ...
pmc.ncbi.nlm.nih.gov
Management of an Unprovoked First Seizure in Adults
www.uptodate.com
Initial treatment of epilepsy in adults - UpToDate
www.uptodate.com
Evaluation and management of the first seizure in adults
www.uptodate.com
Management of an unprovoked first seizure in adults ...
pubmed.ncbi.nlm.nih.gov
Treatment of status epilepticus in adults: guidelines of the ...
pubmed.ncbi.nlm.nih.gov