Evaluation and Treatment of a First Unprovoked Seizure
Evaluation
- Rule out acute symptomatic causes, e.g., meningitis or toxic ingestion. If no acute etiologies are found, the seizure is said to be unprovoked. This type of seizure includes idiopathic seizures (thought to be genetic in origin), remote symptomatic seizures (e.g., in a child with known long-standing cerebral palsy) and cryptogenic seizures (no obvious cause).
- Obtain a detailed history and physical (see Seizure Assessment Tool (AAN) (
41 KB) for an assessment
algorithm).
- Consider laboratory studies such as blood glucose, toxicology, blood chemistries, but only as suggested by clinical history or physical exam in a child older than 6 months.
- Consider performing a lumbar puncture if the child has altered mental status or meningeal signs or is younger than 6 months, but this is usually not necessary otherwise.
- Schedule an EEG to be performed on an outpatient basis sometime after the seizure because it may help determine seizure type and epilepsy syndrome - and hence recurrence risk. EEGs performed very soon after the seizure are often abnormal and might be difficult to interpret.
- Consider imaging, preferably an MRI. This can usually be done on an outpatient basis. Imaging may be helpful in determining seizure etiology, especially if the seizure had a focal onset (eye deviation to one side, 1 side of the body, etc.).
Treatment
- Since only a small percentage of children with a first unprovoked seizure have another seizure, most providers will wait for a second seizure before starting medication, although this decision will depend on seizure length, family preference, etc.
- When considering whether or not to treat a child with antiepileptic drugs after a first seizure, weigh the risks of having a second seizure against the side effects and possible psychosocial aspects of being on daily medication. Waiting to treat until a second seizure allows a better clarification of events and allows the event frequency to be determined.
- Treatment with anti-epileptic drugs (AEDs) may prevent a second seizure, but starting medication is not a guarantee that the child will not have another seizure. [Hirtz: 2003]
- There is no evidence that treatment with AEDS prevents the development of epilepsy or that not treating increases the risk of developing epilepsy.
- Levetiracetam is a possible drug of first choice in this situation because it has few side effects and few drug interactions. Levels and screening laboratory testing are not performed with this medication. If levetiracetam is not successful at the maximum dose, another medication will usually be necessary. The prescribing physician should familiarize themselves with all prescribing information.
Discharge Instructions
- Discuss seizure activity restrictions with the child and family as appropriate. See Activity Restrictions in Children with Seizures.
- Follow-up should be arranged either with the child's medical home clinician or with a pediatric neurologist.
- Develop a seizure action plan with the family that includes
what to do if there is another seizure, and if the seizure was prolonged,
directions for rescue medication in case of another prolonged seizure.
Either rectal diazepam (Diastat) or nasal midazolam (Versed) can be
prescribed if seizures lasts longer than 5 minutes.
- Nasal midazolam is given to each nostril by a mucosal atomizer device. One “kit,” which is what is used at each administration, consists of the total dosage divided into 2 syringes that each have 2 mucosal atomizer devices (MADs). Often, pharmacies need to special order the MADs.
- Provide information regarding the anti-epileptic medication presribed, if any.
- Provide information regarding seizures given to the family. See for an example, Seizure Disorders (FAQ).
Resources
Practice Guidelines
Hirtz D, Ashwal S, Berg A, Bettis D, Camfield C, Camfield P, Crumrine P, Elterman R, Schneider S, Shinnar S.
Practice parameter: evaluating a first nonfebrile seizure in children: report of the quality standards subcommittee of the
American Academy of Neurology, The Child Neurology Society, and The American Epilepsy Society.
Neurology.
2000;55(5):616-23.
PubMed abstract
Recommendations are based on a three-tiered scheme of classification of evidence found in literature review.
Hirtz D, Berg A, Bettis D, Camfield C, Camfield P, Crumrine P, Gaillard WD, Schneider S, Shinnar S.
Practice parameter: treatment of the child with a first unprovoked seizure: Report of the Quality Standards Subcommittee of
the American Academy of Neurology and the Practice Committee of the Child Neurology Society.
Neurology.
2003;60(2):166-75.
PubMed abstract
This parameter reviews published literature relevant to the decision to begin treatment after a child or adolescent experiences
a first unprovoked seizure and presents evidence-based practice recommendations. Reasons why treatment may be considered are
discussed. Evidence is reviewed concerning risk of recurrence as well as effect of treatment on prevention of recurrence and
development of chronic epilepsy. Studies of side effects of anticonvulsants commonly used to treat seizures in children are
also reviewed.
Patient Education
Let's Talk About... Seizures (Intermountain Healthcare)
Brief, 4-page fact sheet about seizures with information about types of seizures, safety during a seizure, and treatment;
Primary Children's Hospital, Intermountain Healthcare.
Tools
Seizure History and Physical Exam Form ( 88 KB)
Offers a format and reminders for performing and recording the physical exam for the child with seizures.
Seizure Assessment Tool (AAN) ( 41 KB)
Questions about signs and symptoms before, during, and after a seizure to help determine seizure type; adapted from the American
Academy of Neurology (2000).
Services for Patients & Families in Idaho (ID)
| Service Categories | # of providers* in: | ID | NW | Other states (6) (show) | | MT | NM | NV | OH | RI | UT |
|---|---|---|---|---|---|---|---|---|---|---|---|
| Pediatric Neurology | 15 | 5 | 17 | 5 | |||||||
For services not listed above, browse our Services categories or search our database.
* number of provider listings may vary by how states categorize services, whether providers are listed by organization or individual, how services are organized in the state, and other factors; Nationwide (NW) providers are generally limited to web-based services, provider locator services, and organizations that serve children from across the nation.
Page Bibliography
Hirtz D, Ashwal S, Berg A, Bettis D, Camfield C, Camfield P, Crumrine P, Elterman R, Schneider S, Shinnar S.
Practice parameter: evaluating a first nonfebrile seizure in children: report of the quality standards subcommittee of the
American Academy of Neurology, The Child Neurology Society, and The American Epilepsy Society.
Neurology.
2000;55(5):616-23.
PubMed abstract
Recommendations are based on a three-tiered scheme of classification of evidence found in literature review.
Hirtz D, Berg A, Bettis D, Camfield C, Camfield P, Crumrine P, Gaillard WD, Schneider S, Shinnar S.
Practice parameter: treatment of the child with a first unprovoked seizure: Report of the Quality Standards Subcommittee of
the American Academy of Neurology and the Practice Committee of the Child Neurology Society.
Neurology.
2003;60(2):166-75.
PubMed abstract
This parameter reviews published literature relevant to the decision to begin treatment after a child or adolescent experiences
a first unprovoked seizure and presents evidence-based practice recommendations. Reasons why treatment may be considered are
discussed. Evidence is reviewed concerning risk of recurrence as well as effect of treatment on prevention of recurrence and
development of chronic epilepsy. Studies of side effects of anticonvulsants commonly used to treat seizures in children are
also reviewed.