A First Unprovoked Seizure (Fit). What’s Next?. Parang Mehta

An unprovoked seizure, or fit, is one that happens without any sickness or injury to the head. People having a seizure often become unconscious for a period. A seizure is scary both in the moment and later — will it happen again? Will it escalate into epilepsy?

Epilepsy can be lifelong and restricts life in several ways. The medicines used for controlling it act on the brain and frequently have unwanted effects.

If you or your child have two unprovoked seizures more than 24 hours apart, your doctor will diagnose epilepsy. They will then prescribe the appropriate medicines to control seizures. If you have had only one seizure, the course of action isn’t as clear.

What is Epilepsy?

Epilepsy is a disorder of the brain that causes seizures. A seizure may cause you to have jerky body movements or go rigid. Some people just have staring spells. These are all types of seizures caused by abnormal electrical discharges in the brain.

Seizures are a hazard. You might fall and lose consciousness wherever you are. This can be dangerous if you’re swimming, driving, on an escalator, or crossing a road. Seizures that go on for a long time (called status epilepticus) can damage the brain.

Epilepsy is one of the most common brain disorders. In America, 5.1 million people have had epilepsy at some time, and 3.4 million have active epilepsy.

People with epilepsy have several restrictions, such as not driving, swimming, and operating heavy machinery. Women with epilepsy have special concerns; hormonal changes around the period can provoke epilepsy. Epilepsy medicines sometimes interfere with birth control medicines. Pregnancy is also worrisome because several of the antiepileptic medicines are harmful to the baby growing in the womb.

Can You Treat Epilepsy?

Yes, certainly. If you have epilepsy, your healthcare provider will refer you to a neurologist or epileptologist.

Good epilepsy control needs regular treatment, avoidance of provoking factors (such as flashing or bright lights), getting enough sleep, reducing stress, and consulting your doctor regularly. There are various treatment options:

Medicines. Anti-seizure medicines prevent seizures from happening and spreading. There are many types; your specialist will prescribe the one most likely to work for you. Over time, your doctor and you will find the optimum medicine and dose for you.

Surgery. When a part of the brain is generating seizures, your doctor may offer surgery to remove it. This is not an early option and is only chosen when medicines are not providing adequate seizure control.

Other treatments. These are often tried when medicines do not work and surgery isn’t possible. Treatments like vagus nerve stimulation and the ketogenic diet help in some people.

But After a First Unprovoked Seizure?

Epilepsy is an ancient disease, and doctors have studied it a lot. After one unprovoked seizure:

27% of adults and children will have a second seizure in the first six months.
36% will have a second seizure in the first year.
43% will have a second seizure in the first two years.

Two out of five people having an unprovoked seizure are likely to experience another. Children have a slightly higher chance of having a second seizure than adults. Obviously, three out of five people will never have a second seizure.

Seizures are scary and can cause injuries or death. However, the treatment of epilepsy has its own dangers. Medicines have to be taken for several years or lifelong, and your doctor will probably not begin such arduous treatment after one seizure.

They will want to do some tests to find an underlying cause. Some of these include low blood sugar, stroke, an unrecognized brain injury in the past, childbirth complications, and some genetic disorders. Epilepsy doesn’t have an identifiable cause in most people.

What Doesn’t Increase Further Seizure Risk

Your age
Your gender
Other people in your family having a seizure disorder
The type of seizure
Multiple discrete seizures within 24 hours

What Can You Do for Someone Having a Seizure?

If you see someone having a seizure, don’t try to force the seizure to stop. Stay with them and ensure they don’t hurt themselves. When they are awake and able to talk, tell them what happened to them. They may need a taxi to get home safely.

It’s dangerous to force anything into the mouth. A hard object can damage the teeth or jaw. Food and drink may enter the airway and lead to aspiration pneumonia. People having a seizure don’t need cardiopulmonary resuscitation (CPR); their breathing returns to normal when the seizure ends.

What about getting them to a hospital or emergency room? You should consider it if:

The seizure goes on for a long time.
The person is injured during the seizure.
They have another seizure shortly after the first ends.
You know them, and they’ve never had a seizure before.
They have a health condition like diabetes or heart disease.
Pregnancy.

What Treatment Do You Need?

Given that more than half of people having one unprovoked seizure never have another, your doctor will probably not want to start antiepileptic drugs (AEDs). These drugs work on the brain, have to be taken for a long time once started, and 7 to 31% of people taking them have adverse effects.

Under some situations, your doctor may consider prescribing AEDs. These include:

A seizure during the night
Earlier brain damage by injury or illness
Abnormal electroencephalogram (EEG)
Abnormalities seen on brain scans.

AEDs started after a first seizure are somewhat beneficial — they reduce the likelihood of seizures in the two years following the first seizure by about 35%. In the long term, though, they don’t prevent seizures. In other words, AEDs after a first unprovoked seizure don’t protect you against the development of epilepsy.

Are Things Different for Your Child?

The concerns when a child has a seizure are different. Your pediatrician will want to ascertain that the event was, in fact, an unprovoked seizure. As a first step, they’ll likely look for serious conditions that can cause seizures. Unlike adults, some of these remain unnoticed until the seizure.

Febrile seizures. These are seizures associated with fever and are rarely dangerous. Sometimes, the fever is low or appears a while after the febrile seizure.

Head trauma. Children are endlessly energetic and curious and often take falls and blows to the head. Injuries that seemed minor at the time or went unknown can cause seizures after months or years.

Intracranial infection. Universal vaccination against pneumococci and Hemophilus influenzae type b has made meningitis infrequent now. However, they’re dangerous infections, often fatal, and frequently leave sequelae in survivors. Your pediatrician will make sure your child doesn’t have meningitis or encephalitis.

Metabolic disturbances. Abnormal blood levels of calcium, sugar, magnesium, and other important substances can sometimes cause seizures in a child. Correction of these metabolic abnormalities is essential and curative; antiepileptic medicines aren’t needed. Conditions known as inborn errors of metabolism can also first appear as seizures.

Genetic syndromes. These usually show themselves during childhood. If your pediatrician diagnoses one of these, treatment may be lifelong.

Epilepsy is a serious disorder. However, your pediatrician will probably not initiate antiepileptic treatment after the first seizure. Long-term daily treatment with drugs acting on the brain can be more harmful than seizures happening again. Your pediatrician will carefully consider the advantages of treatment against the risks before advising such treatment.

The Bottom Line

A seizure is a momentous event, both for your health and quality of life. Your doctor may advise you against driving, swimming, operating machinery, and other important parts of life and work.

Adults having a first unprovoked seizure have a two in five chance of further seizures over the next two years.

Antiepileptic medicines can reduce the likelihood of seizures by about a third (35%). Though this sounds impressive, it doesn’t lift the safety restrictions since you’re still likely to have a seizure and suffer the consequences.

A significant proportion of people have adverse effects while taking these medicines.

Antiepileptic drugs taken immediately after a first unprovoked seizure do not prevent the development of epilepsy.

Earlier brain injury, abnormal EEG or scans, and seizures at night have a high likelihood of further seizures. Your doctor may consider starting treatment even after just one seizure.

References

National Institute for Health and Care Research. Epilepsy: what are the chances of having a second seizure?
Centers for Disease Control and Prevention. Frequently Asked Questions About Epilepsy.
Epilepsy Foundation. Women.
Centers for Disease Control and Prevention. Epilepsy.
Pediatrics in Review. Seizures in Children.
Evidence-based guideline: Management of an unprovoked first seizure in adults. Report of the Guideline Development Subcommittee of the American Academy of Neurology and the American Epilepsy Society.