AAN 2022 | Should patients with a single unprovoked seizure be evaluated and treated as if they have epilepsy?

Anteneh Feyissa, MD, FAAN, Mayo Clinic, Jacksonville, FL, discusses whether patients with a single unprovoked seizure should be evaluated and treated as if they have epilepsy. Dr Feyissa shares his arguments on why waiting for a second seizure before declaring the diagnosis of epilepsy and initiating treatment with antiseizure medications is a reasonable approach. Firstly, several studies have consistently shown that patients with no risk factors for recurrence are unlikely to have epilepsy. Studies examining the benefits of initiating therapy in those patients found no differences in short- and long-term outcomes between those treated early or when treatment was delayed. In patients with significant risk factors for recurrence, waiting for a second seizure may be a better approach. Data shows a reduction of recurrence in the short term for patients treated after their index seizure, but long-term outcomes were nearly identical. And there is little evidence to suggest that immediate treatment brings any short-term benefits in quality of life. Besides, a study found that prompt treatment with antiseizure medication did not impact survival or mortality over the next 25 years. A further argument for waiting before starting epilepsy treatment is that epilepsy will declare itself rather quickly – studies have shown that epilepsy patients are likely to have a recurrence within 3 to 6 months after the first seizure. It is also essential to consider the occurrence of seizure mimics, which can reach up to 40% in those presenting first-time seizures. An epilepsy diagnosis comes with secondary handicaps, and a misdiagnosis exposes patients to unnecessary antiseizure medications and their related side effects; therefore, more studies are needed for clinicians to make better-informed decisions. This interview took place at the American Academy of Neurology 2022 Congress in Seattle, WA.