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Guidelines Offer No Set Recommendations for How to Deal with First Seizures

by U.S. Medicine

February 6, 2016

Response Differs When Veteran, Servicemember Had Exposure to Blasts

By Annette M. Boyle

BALTIMORE — While veterans and servicemembers who have experienced a single unprovoked seizure and the clinicians who treat them would like clear, consistent next steps, new guidelines take them into solidly gray areas.

“Some physicians treat everyone with first seizure; some don’t treat anyone. The new guidelines do not give a black-and-white answer. They say treatment and management really needs to be individualized,” said Allan Krumholz, MD, director of the Maryland Veterans Affairs Epilepsy Center of Excellence and professor of neurology at the University of Maryland School of Medicine in Baltimore.

Krumholz was the lead author of guidelines published this fall by the American Academy of Neurology (AAN) and the American Epilepsy Society (AES). The report in Neurology was the fourth in a series on managing epilepsy in children and adults.1

The professional organizations recommend weighing the risk of another seizure and how a subsequent seizure might affect the patient’s life against tolerance of side effects, patient preferences and risk of antiepileptic medications to develop the best strategy for the individual.

EEG technician Susan Hayes administers testing to an epilepsy study participant at the Durham, NC, VAMC VA Photo by Pete Tillma)

EEG technician Susan Hayes administers testing to an epilepsy study participant at the Durham, NC, VAMC VA Photo by Pete Tillma)

Patient education and joint decision-making are key to the approach. “It’s very different from the usual paternalistic or maternalistic attitude toward treatment,” Krumholz told U.S. Medicine.

Education includes clearly conveying the risk of a second seizure, which is highest in the two years following an initial unprovoked seizure. During this period, the risk ranges from 21% to 45%. Medications can cut that rate in half, according to Krumholz.

Predicting who is most likely to experience another seizure is not quite a shot in the dark, however. Four factors double a patient’s risk:

  • a prior brain insult, such as a concussion that caused the seizure,
  • an EEG that shows spikes or epileptiform abnormalities,
  • a significant brain-imaging abnormality such as a lesion, or
  • a first seizure during sleep.

The recommendations note that “caution is urged regarding the calculation of additive risk of seizure recurrence after a first unprovoked seizure,” as the interaction of the various risk factors remains unknown.

How or why all four increase risk also remains unclear. “The first three factors have a logical foundation,” Krumholz explained. “We don’t know why nocturnal seizures are associated with increased risk, but we saw a correlation in two studies.”

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Blast-Injury Effect

About 23% of seizure patients have abnormal EEGs, according to the 2007 AAN/AES guideline on evaluating an unprovoked first seizure. Another 10% have significant brain abnormalities. For veterans, though, the biggest risk may be from traumatic brain injury (TBI).

“While people who have history of epilepsy aren’t able to serve, seizures can be significant problem for veterans,” Krumholz noted. “Many of those returning from Iraq and Afghanistan have had head injuries, and we’re not really sure how that will impact their risk for seizure in the long term, particularly for those who have suffered blast injuries.”

For VA or DoD physicians, asking about previous concussions or related injuries may tip the scale toward starting a veteran on antiepileptic medications after a first seizure, he suggested.

For patients without underlying causes or other risk factors, the physician might want to wait to see whether a subsequent episode occurs, according to the new guidelines. Reducing the risk of a subsequent seizure by initiating medical therapy also could make sense, if a veteran’s livelihood would be imperiled by another seizure, as might occur for a truck driver or heavy machinery operator, or for those who would suffer acute psychological or social consequences, such as veterans who live in isolated rural locations.

On the other hand, patients and physicians might decide to delay therapy because many patients never have a second seizure, and the side effects of antiepileptic medications can be significant. The guideline authors found that patients had a 7% to 14% risk of adverse effects from taking antiepileptic drugs. Common side effects include sleep disturbances, confusion, altered mood, impaired cognition, hyperactivity and behavioral changes. The side effects abated when patients stopped taking the drugs.

Stopping the medications does not eliminate all downsides, however. The risk of seizure increases 30% in the year immediately following discontinuation, with most seizures occurring within the first three to six months. Some physicians advise patients not to drive during the highest risk period.

Immediate treatment with antiepileptic drugs was not associated with a better long-term prognosis for freedom from seizures or with improved quality of life in the two years following the initial unprovoked seizure, although researchers said patients that did not start medications were more likely to be restricted from driving.

Once patients start on medications, there is no strong evidence to support how long to continue to treat the for seizures, according to Krumholz. “Most physicians, including myself, would treat someone for two to four years to be sure they are seizure-free, then could consider stopping medication.” If patients experience seizures again, medication can be restarted, he noted.

The guidelines focus on patients who have had only one seizure, because the question of treatment changes substantially following a second seizure. Patients who experience more than one seizure should be treated, as their risk for additional seizures rises to about 80% in the future, Krumholz emphasized.

Before starting antiepileptic medications, physicians will want to ensure that the seizures are epileptic. Epileptic and nonepileptic seizures, such as those associated with psychogenic non-epileptic syndrome (PNES), can look very similar to observers and feel very similar to patients, according to VA research. Antiepileptics do not help with PNES, for which the recommended treatments are cognitive behavior therapy and psychotropic medications.

  1. Krumholz A, Wiebe S, Gronseth GS, Gloss DS, Sanchez AM, Kabir AA, Liferidge AT, Martello JP, Kanner AM, Shinnar S, Hopp JL, French JA. Evidence-based guideline: Management of an unprovoked first seizure in adults. Neurology. 2015;84:1705–1713.

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