Should a first seizure be treated with seizure medicine?

The answer depends on the type of seizure.

  • When a health care provider sees a person after their first seizure, they will try to find out if the seizure was triggered by something specific, such as a head injury, infection, or a reaction to alcohol or some other drug.
  • If a clear trigger is identified and has resolved or can be avoided in the future, then treatment with an anti-seizure medicine may not be needed.
  • A seizure medicine is usually started if a person has had more than one seizure. Yet, a medicine may also be started if a person has only one seizure but other tests (such as an MRI or EEG) suggest a risk for more seizures in the future.
    • When a child has had a single absence seizure and the EEG shows a typical pattern associated with this seizure type, then it's likely that the child has had other unwitnessed staring events. In this situation, a seizure medicine is usually recommended.
    • A person who had been diagnosed with partial seizures may have had previous events that were not noticed or recognized as seizures. Unfortunately, many people don't see a doctor unless a more pronounced event or convulsion has occurred. If a partial seizure has definitely occurred, many doctors recommend treatment, because there is a high chance of having more seizures.
    • The question is more difficult for a single tonic-clonic (grand mal) seizure. The chance of another seizure can range from 16% to 61%, depending on the circumstances surrounding the seizure and results of a neurological exam or other tests.
  • A seizure medication is usually not started if:
    • The neurological examination is normal.
    • The results of neuroimaging studies (CT or MR scan) are normal.
    • The EEG is normal.
    • A specific trigger is found that can be eliminated.
    • The seizure occurred during sleep.
    • There is no family history of epilepsy.
  • Guidelines on when to treat a first seizure found that starting seizure medications after the first seizure can lessen the risk for more seizures in the first 2 years. The report also found:
    • When an adult has an unprovoked seizure, the risk for more seizures without treatment in the next 2 years can range 21 to 45%.
    • This risk is greatest in people who have had a brain injury (such as stroke or trauma) and seizure activity is seen on the EEG. Other factors that may lead to a higher risk for seizures in the first 2 years are other abnormalities on brain imaging tests and seizures at night.
    • Starting a seizure medication right away may help lessen this early risk, but does not seem to affect the long-term risk of seizures.
    • The risk of side effects from seizure medications may range from 7 to 31%. Medication side effects are usually mild and go away
    • Early treatment may not affect the person's quality of life over time.

Who makes the decision about taking seizure medicine?

The person who has had the seizure and their family should talk with their doctor about the pros and cons of starting a seizure medicine. Factors that can influence choices about medicine include:

  • The type of seizure.
  • The type of epilepsy (remember that epilepsy is a condition where a person can have multiple seizures over time).
  • Results of diagnostic tests (such as MRI, CT and EEG).
  • The risk of seizure recurrence or of having more seizures. This can often be predicted by history, examination, and test results.
  • The person's willingness to take the risk of having another seizure before starting medicine.
  • The person's lifestyle (for example driving or not driving, living alone, working or not working, caring for small children)
  • Potential side effects of different medicines.

If a person has been taking medicine after having just one seizure but doesn't have any more after a period of time, they should talk to their health care team to see if medicine can be stopped.

Authored By: 
Steven C. Schachter MD
Patricia O. Shafer RN, MN
Joseph I. Sirven MD
Robert T. Wechsler MD, PhD
Authored Date: 
Wednesday, May 20, 2015
Reviewed By: 
Robert Wechsler MD, PhD
Medication Editor
Reviewed Date: 
Wednesday, May 20, 2015