• Seizures occur commonly and it is estimated that 1 of 26 people will develop epilepsy at some point in their life.
• A first seizure provoked by an acute brain insult is less likely to recur (3-10%) than a first-time unprovoked seizure (30-50% over the next 2 years).
• As an emergency provider managing an adult who presents with their first-ever seizure, there are four primary questions that require answering:

1. Was it in fact a true seizure? (often associated with tongue biting, urinary/bowel incontinence, preceding aura, post-ictal phase; examples of seizure mimics include syncope (i.e. cardiogenic, neurogenic, vasovagal), vertigo, myoclonic jerking, psychogenic convulsions, movement disorders.)
2. Does the patient have epilepsy? (defined a having at least 2 unprovoked epileptic seizures by any immediately identifiable cause.)
3. What type of epilepsy? (cryptogenic (i.e. of unknown etiology) or symptomatic (i.e. caused by prior central nervous system insult such as brain injury.)
4. What is the cause? (metabolic panels to assess for uremia, electrolyte and glucose abnormalities, and drug intoxications should be performed, as well brain imaging to determine the presence of focal intracranial lesions.)

• Many patients do not require anticonvulsant medication following a single, first time seizure; A general consensus is that such therapy should be strongly considered for initiation after a second episode of seizure activity. 

References

• Engel J Jr. Report of the ILAE classification core group. Epilepsia. Sep 2006;47(9):1558-68.
• Hesdorffer DC, Logroscino G, Benn EK, Katri N, Cascino G, Hauser WA. Estimating risk for developing epilepsy: a population-based study in Rochester, Minnesota. Neurology. Jan 4 2011;76(1):23-7.
• Pohlmann-Eden B, Beghi E, Camfield C, Camfield P. The first seizure and its management in adults and children. BMJ. Feb 11 2006;332(7537):339-42.