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neuro.first-seizure-eval.v1

First Unprovoked / New-Onset Seizure Evaluation (adult)

neurologysubacuteadultpregnancygeriatric
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Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Adult presenting after a single new paroxysmal event — frame as is-it-a-seizure → provoked-vs-unprovoked → recurrence-risk/ASM decision (AAN/AES 2015 Krumholz PMID 25901057; ILAE 2014 Fisher PMID 24730690)

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Advance rule
Set
Advance when

Single-event presentation framed; SE excluded (not continuous ≥5 min)

Patient inputs (26)

EEG recommended after first unprovoked seizure — epileptiform abnormality (~23%) predicts recurrence; sleep-deprived/repeat raises yield (Krumholz 2007 PMID 18025394; King PMID 9759742)

Epilepsy-protocol MRI superior to CT for structural cause; abnormality is a higher-recurrence modifier (AAN/AES 2015 Krumholz PMID 25901057; King PMID 9759742)

Elderly have lower recurrence threshold from structural disease + ASM interaction/fall risk; childbearing-potential branch drives ASM choice (AAN/AES 2015 Krumholz PMID 25901057)

People of childbearing potential — valproate hard-contraindicated (teratogenic/neurodevelopmental); prefer lamotrigine/levetiracetam + folate (NICE NG217 2022)

Eclampsia (pregnancy ≥20 wk or postpartum) → route OB, MgSO4 not ASM; pregnancy alters ASM selection + folate (NICE NG217 2022)

Acute-symptomatic if within 7 d of stroke/TBI/CNS infection or active metabolic/toxic insult → treat cause, generally NO long-term ASM (ILAE 2014 Fisher PMID 24730690; Krumholz PMID 25901057)

Alcohol-withdrawal seizure → benzodiazepine pathway, NOT chronic ASM (distinct pathway; NICE NG217 2022)

Prolonged post-ictal confusion favours epileptic seizure; rapid recovery favours convulsive syncope (Sheldon point score PMID 12103268)

Presyncopal prodrome / upright posture / situational trigger favours convulsive syncope; sleep-deprivation/photic favours epileptic (Sheldon PMID 12103268; MESS Marson PMID 15950714)

Driving restriction is jurisdiction-dependent and a core counselling deliverable; occupation (heights/machinery) drives shared ASM decision (AAN/AES 2015 Krumholz PMID 25901057)

Eyewitness account is the single most load-bearing test — onset, motor pattern, automatisms, duration, cyanosis (King PMID 9759742; ILAE 2017 Scheffer PMID 28276062)

Hypo/hyperglycaemia is a reversible provoking cause — immediate fingerstick (AAN/AES 2015 Krumholz PMID 25901057)

Hyponatraemia (and hypernatraemia) provoke seizures — correct cause; correction-rate matters (AAN/AES 2015 Krumholz PMID 25901057)

Hypocalcaemia provokes seizures (ionised preferred); reversible cause (AAN/AES 2015 Krumholz PMID 25901057)

Uraemia and hepatic failure provoke seizures; eGFR/LFT also gate ASM dose selection (CKD-EPI 2021 for renal ASM dosing)

Pregnancy test in people of childbearing potential — eclampsia screen + ASM teratogenicity decision (NICE NG217 2022)

ECG to exclude cardiac syncope / long-QT / Brugada — an important and dangerous seizure mimic (Sheldon PMID 12103268)

Continuous ≥5 min OR recurrent without recovery → status epilepticus pathway takes precedence (route to neuro.status-epilepticus.core.v1)

Focal deficit / persistent altered mental status → urgent neuroimaging ± LP; acute-symptomatic structural or infectious cause (AAN/AES 2015 Krumholz PMID 25901057)

Prior stroke/TBI/CNS infection/tumour/perinatal injury = remote symptomatic — higher recurrence; meets epilepsy definition risk (AAN/AES 2015 Krumholz PMID 25901057)

Acute CT if focal deficit / persistent AMS / trauma / anticoagulation / immunocompromised / new severe headache (AAN/AES 2015 Krumholz PMID 25901057)

Lateral tongue-bite has high specificity / strong LR+ for epileptic GTC vs syncope (Sheldon point score PMID 12103268)

Eyes closed, ictal weeping, very long duration, fluctuating course, pelvic thrusting, resistance to eye opening favour PNES → video-EEG, NOT ASM (NICE NG217 2022)

Hypomagnesaemia provoking factor; relevant to eclampsia/MgSO4 (NICE NG217 2022)

Drug intoxication/withdrawal is a reversible provoking cause (cocaine, sympathomimetics, tramadol, bupropion, isoniazid) (AAN/AES 2015 Krumholz PMID 25901057)

Nocturnal/sleep-related seizure is an independent higher-recurrence modifier (AAN/AES 2015 Krumholz PMID 25901057)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (7)

7 need judgement
  • informationallife_threateningseizure_in_evolution_or_recurrent
    Continuous seizure ≥5 min OR recurrent seizures without recovery to baseline (ILAE 2015 operational definition of status epilepticus)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverefocal_deficit_or_persistent_AMS
    New focal neurological deficit OR persistent altered mental status after the event — acute-symptomatic structural/infectious cause
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverereversible_metabolic_or_eclampsia
    Hypoglycaemia, severe hyponatraemia, hypocalcaemia, uraemia/hepatic, OR pregnancy ≥20 wk / postpartum (eclampsia) — immediately reversible provoking cause
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatehigh_recurrence_unprovoked
    Unprovoked seizure with remote brain insult AND/OR epileptiform EEG AND/OR significant MRI lesion AND/OR nocturnal seizure → 2-yr recurrence approaching/≥60%
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatesuspected_PNES
    Eyes closed, ictal weeping, very long duration, fluctuating/asynchronous movements, pelvic thrusting, resistance to eye opening, high psychiatric comorbidity — psychogenic non-epileptic seizure suspected
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatealcohol_withdrawal_seizure
    Seizure in the context of alcohol withdrawal (typically 6–48 h after reduction) — distinct withdrawal-spectrum pathway
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatechildbearing_potential_aed_decision
    Person of childbearing potential requiring an ASM — valproate teratogenicity/neurodevelopmental hard contraindication
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

RISK_STRATIFICATIONoptionalDrives screening
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Recommended regimen

First unprovoked seizure — ASM selection by seizure type + childbearing-potential branch (AAN/AES 2015 Krumholz PMID 25901057; NICE NG217 2022; SANAD II)
axis: first_seizure_aedstep 1 - Step 1 — Decide WHETHER to start an ASM (shared decision)
Selected step "Step 1 — Decide WHETHER to start an ASM (shared decision)" — Unprovoked single seizure with normal/uncertain work-up — recurrence ~21–45% at 2 yr
  • no ASM — observe with safety-net + driving/safety counselling
    first line
    shared_decision
    triggers: low_recurrence_risk, normal_eeg_and_mri, patient_prefers_defer
    AAN/AES 2015 (Krumholz PMID 25901057) + MESS (Marson Lancet 2005 PMID 15950714) — immediate ASM reduces 2-yr recurrence but does NOT improve long-term remission/QoL; defer is reasonable when recurrence risk low and patient values favour it
  • start ASM — epilepsy diagnosed (recurrence risk ≥60% OR ≥2 unprovoked >24 h apart OR epilepsy syndrome)
    first line
    shared_decision
    triggers: recurrence_risk_ge_60pct, two_unprovoked_seizures, epileptiform_eeg_with_remote_insult, epilepsy_syndrome
    ILAE 2014 operational definition (Fisher PMID 24730690) — epilepsy can be diagnosed after ONE seizure when 2-yr recurrence ≥60% (e.g., remote symptomatic + epileptiform EEG); treat as epilepsy

outpatient playbook — drug actions (5)

  1. 1. no ASM — observe with safety-net (shared decision)
    n/a • n/a • n/a
    trigger: Low recurrence risk + normal EEG/MRI + patient prefers defer
    MESS (Marson Lancet 2005 PMID 15950714) + FIRST (PMID 9339678) — immediate ASM reduces 2-yr recurrence but not long-term remission/QoL
  2. 2. lamotrigine (focal-onset or childbearing potential)
    25 mg PO daily → slow titration to 100–200 mg BID • PO • BID
    trigger: Epilepsy diagnosed, focal-onset or childbearing potential
    SANAD II + NICE NG217 2022 — focal-onset / childbearing-potential preferred; slow titration for rash
  3. 3. levetiracetam (focal or generalised; childbearing potential)
    250–500 mg PO BID → 500–1500 mg BID • PO • BID
    trigger: Epilepsy diagnosed; rapid control or minimal interactions needed
    NICE NG217 2022 — broad-spectrum, childbearing-potential-safe; counsel behavioural/mood adverse effects
  4. 4. valproic acid (generalised, childbearing potential EXCLUDED)
    200–500 mg PO BID • PO • BID
    trigger: GGE + childbearing potential excluded + other broad-spectrum unsuitable
    Most effective GGE ASM but HARD-CONTRAINDICATED in childbearing potential — pregnancy-prevention programme only (NICE NG217 2022)
  5. 5. folic acid (childbearing potential)
    5 mg PO daily • PO • daily
    trigger: Childbearing potential on/considering ASM
    Pre-conception neural-tube-defect prevention; pre-pregnancy ASM optimisation off valproate

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: First lifetime witnessed convulsive event — is-it-a-seizure work-up (AAN/AES 2015 Krumholz PMID 25901057); Transient loss of consciousness of uncertain cause — seizure vs syncope vs PNES (Sheldon point score PMID 12103268); New focal aware / focal impaired-awareness episode (déjà vu, automatisms, sensory aura) — ILAE 2017 classification (Scheffer PMID 28276062).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**First Unprovoked / New-Onset Seizure Evaluation (adult)** (neuro.first-seizure-eval.v1).
Phenotype framing: Three-way partition: (a) epileptic seizure (lateral tongue-bite, prolonged post-ictal confusion — Sheldon PMID 12103268); (b) convulsive/cardiac syncope (prodrome, upright, rapid recovery — route symptom.syncope.ed.v1); (c) PNES (eyes closed, fluctuating, long duration → video-EEG, NOT ASM)
Scope: Adult presenting after a single new paroxysmal event — frame as is-it-a-seizure → provoked-vs-unprovoked → recurrence-risk/ASM decision (AAN/AES 2015 Krumholz PMID 25901057; ILAE 2014 Fisher PMID 24730690)

No severity triggers fired against current inputs.

Plan

Regimen axis: **First unprovoked seizure — ASM selection by seizure type + childbearing-potential branch (AAN/AES 2015 Krumholz PMID 25901057; NICE NG217 2022; SANAD II)** — step "Step 1 — Decide WHETHER to start an ASM (shared decision)".
1. no ASM — observe with safety-net + driving/safety counselling (shared_decision, first line) — AAN/AES 2015 (Krumholz PMID 25901057) + MESS (Marson Lancet 2005 PMID 15950714) — immediate ASM reduces 2-yr recurrence but does NOT improve long-term remission/QoL; defer is reasonable when recurrence risk low and patient values favour it
2. start ASM — epilepsy diagnosed (recurrence risk ≥60% OR ≥2 unprovoked >24 h apart OR epilepsy syndrome) (shared_decision, first line) — ILAE 2014 operational definition (Fisher PMID 24730690) — epilepsy can be diagnosed after ONE seizure when 2-yr recurrence ≥60% (e.g., remote symptomatic + epileptiform EEG); treat as epilepsy

Setting playbook (outpatient) — First-seizure clinic — confirm seizure vs mimic, classify provoked/unprovoked, integrate EEG + epilepsy-protocol MRI, recurrence-risk stratify, shared ASM decision, deliver driving/SUDEP/trigger/pregnancy counselling (AAN/AES 2015 Krumholz PMID 25901057; NICE NG217 2022)
3. no ASM — observe with safety-net (shared decision) n/a n/a n/a — Low recurrence risk + normal EEG/MRI + patient prefers defer (MESS (Marson Lancet 2005 PMID 15950714) + FIRST (PMID 9339678) — immediate ASM reduces 2-yr recurrence but not long-term remission/QoL)
4. lamotrigine (focal-onset or childbearing potential) 25 mg PO daily → slow titration to 100–200 mg BID PO BID — Epilepsy diagnosed, focal-onset or childbearing potential (SANAD II + NICE NG217 2022 — focal-onset / childbearing-potential preferred; slow titration for rash)
5. levetiracetam (focal or generalised; childbearing potential) 250–500 mg PO BID → 500–1500 mg BID PO BID — Epilepsy diagnosed; rapid control or minimal interactions needed (NICE NG217 2022 — broad-spectrum, childbearing-potential-safe; counsel behavioural/mood adverse effects)
6. valproic acid (generalised, childbearing potential EXCLUDED) 200–500 mg PO BID PO BID — GGE + childbearing potential excluded + other broad-spectrum unsuitable (Most effective GGE ASM but HARD-CONTRAINDICATED in childbearing potential — pregnancy-prevention programme only (NICE NG217 2022))
7. folic acid (childbearing potential) 5 mg PO daily PO daily — Childbearing potential on/considering ASM (Pre-conception neural-tube-defect prevention; pre-pregnancy ASM optimisation off valproate)

Non-pharmacologic actions:
- Driving-restriction counselling per jurisdiction — counsel AND document (e.g., seizure-free interval before resuming; clinician notification duties vary by region)
- Safety counselling — supervised swimming, showers not baths, avoid heights/dangerous machinery, occupational review
- SUDEP discussion (individualised; adherence + nocturnal-seizure relevance)
- Trigger-avoidance — sleep hygiene, alcohol moderation, adherence, photic if photosensitive
- Pregnancy-planning counselling for childbearing potential — off valproate, folate, ASM registry
- Seizure first-aid education for patient + family; recurrence-action plan
- Refer psychiatry/psychotherapy if PNES suspected/confirmed — NOT ASM

AVOID / contraindication checks:
- Valproate_hard_contraindicated_in_childbearing_potential — teratogenic + dose dependent neurodevelopmental harm; pregnancy prevention programme only (NICE NG217 2022)
- Avoid_sodium_channel_blockers_in_genetic_generalised_epilepsy — carbamazepine/oxcarbazepine/phenytoin/lacosamide can worsen absence/myoclonic seizures in GGE (NICE NG217 2022)
- HLA_B_1502_test_before_carbamazepine_oxcarbazepine_in_at_risk_ancestry — SJS/TEN risk (NICE NG217 2022)
- Lamotrigine_slow_titration_for_rash — Stevens–Johnson/DRESS; reduce titration further with valproate co therapy (NICE NG217 2022)
- Carbamazepine_oxcarbazepine_hyponatraemia_and_enzyme_induction — monitor Na; reduces hormonal contraceptive efficacy (NICE NG217 2022)
- Do_NOT_start_chronic_ASM_for_acute_symptomatic_or_single_provoked_seizure — treat the cause (AAN/AES 2015 Krumholz PMID 25901057; ILAE 2014 Fisher PMID 24730690)
- Do_NOT_treat_PNES_with_ASM — psychiatric/psychological care; video EEG gold standard (NICE NG217 2022)
- Alcohol_withdrawal_seizure_is_benzodiazepine_managed_not_chronic_ASM (NICE NG217 2022)
- Renal_dose_adjust_levetiracetam_lacosamide_brivaracetam_zonisamide (eGFR via CKD EPI 2021)
- Levetiracetam_perampanel_behavioural_psychiatric_signal — screen mood (PHQ 9/GAD 7) before + during therapy

Monitoring

Regimen monitoring:
- Seizure diary at every visit — frequency, semiology, triggers (sleep deprivation, alcohol, missed doses, photic)
- ASM clinical response + tolerability at 2–4 wk then 3–6 monthly (NICE NG217 2022)
- Sodium for carbamazepine/oxcarbazepine; LFT + CBC for valproate/carbamazepine at baseline + as indicated
- ASM level only if toxicity/adherence/pregnancy/interaction concern (levels not routinely needed — NICE NG217 2022)
- PHQ-9 + GAD-7 at baseline, ~90 d, then annually (psychiatric comorbidity ~30%; ASM suicidality signal)
- eGFR (CKD-EPI 2021) for renally-cleared ASMs; bone-health review for chronic enzyme-inducers
- Pregnancy-prevention-programme review for valproate; folate 5 mg/day + pre-conception ASM review for childbearing potential

Setting (outpatient) monitoring:
- Seizure diary review each visit
- ASM tolerability/response at 2–4 wk then 3–6 monthly if started
- Na for carbamazepine/oxcarbazepine; LFT/CBC for valproate/carbamazepine as indicated
- PHQ-9/GAD-7 at baseline, ~90 d, annually
- Re-evaluate epilepsy diagnosis + ASM need if a second seizure occurs

Follow-up plan: Driving-restriction counselling (jurisdiction-dependent — counsel AND document), safety (swimming/heights/bathing/occupational), SUDEP discussion, alcohol/sleep-deprivation trigger avoidance, ASM individualisation, pregnancy planning + folate for childbearing potential, re-evaluate epilepsy diagnosis if second seizure (AAN/AES 2015 Krumholz PMID 25901057; ILAE 2014 Fisher PMID 24730690)
- Close-out criterion: Counselling delivered + documented; recurrence-action plan given

Monitoring phase: First-seizure clinic re-assessment with EEG/MRI results; seizure diary; if ASM started — clinical response, ASM tolerability/levels, labs (LFT/CBC/Na for relevant ASMs); PHQ-9/GAD-7 (psychiatric comorbidity ~30%) (NICE NG217 2022)

Disposition

Current setting: outpatient — First-seizure clinic — confirm seizure vs mimic, classify provoked/unprovoked, integrate EEG + epilepsy-protocol MRI, recurrence-risk stratify, shared ASM decision, deliver driving/SUDEP/trigger/pregnancy counselling (AAN/AES 2015 Krumholz PMID 25901057; NICE NG217 2022)

Disposition criteria:
- Continue observation without ASM if single unprovoked low-risk seizure and patient values defer
- Start ASM + ongoing epilepsy follow-up if epilepsy diagnosed (≥60% recurrence, ≥2 seizures, or syndrome)
- Discharge acute-symptomatic seizures to cause-directed follow-up without chronic ASM
- Refer drug-resistant or diagnostically uncertain cases to tertiary epilepsy service

Escalation triggers (move to higher acuity):
- Second unprovoked seizure >24 h after first → epilepsy diagnosed (ILAE 2014 Fisher PMID 24730690) → start/optimise ASM
- Recurrent or prolonged seizure → ED; if ≥5 min → SE pathway (route neuro.status-epilepticus.core.v1)
- Suspected PNES → video-EEG + psychiatry referral (do NOT escalate ASM)
- PHQ-9 ≥15 or suicidal ideation → urgent psychiatry (ASM suicidality signal)
- Pregnancy declared on valproate → urgent specialist review + ASM switch planning

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Continuous seizure ≥5 min OR recurrent seizures without recovery to baseline (ILAE 2015 operational definition of status epilepticus)
- [SEVERE] New focal neurological deficit OR persistent altered mental status after the event — acute-symptomatic structural/infectious cause
- [SEVERE] Hypoglycaemia, severe hyponatraemia, hypocalcaemia, uraemia/hepatic, OR pregnancy ≥20 wk / postpartum (eclampsia) — immediately reversible provoking cause

Citations

- AAN/AES 2015 Evidence-Based Guideline — Management of an Unprovoked First Seizure in Adults (Krumholz, Neurology 2015) + ILAE 2014 Operational Definition of Epilepsy (Fisher, Epilepsia 2014) + NICE NG217 (2022) Epilepsies + ILAE 2017 Classification (Scheffer, Epilepsia 2017) + MESS (Marson, Lancet 2005) + FIRST Seizure Trial [PMID:25901057](https://pubmed.ncbi.nlm.nih.gov/25901057/)
- Cited evidence (PMID 24730690) [PMID:24730690](https://pubmed.ncbi.nlm.nih.gov/24730690/)
- Cited evidence (PMID 18025394) [PMID:18025394](https://pubmed.ncbi.nlm.nih.gov/18025394/)
- Cited evidence (PMID 15950714) [PMID:15950714](https://pubmed.ncbi.nlm.nih.gov/15950714/)
- Cited evidence (PMID 16545748) [PMID:16545748](https://pubmed.ncbi.nlm.nih.gov/16545748/)

Last reconciled with current guidelines: 2026-05-26.
References
  • AAN/AES 2015 Evidence-Based Guideline — Management of an Unprovoked First Seizure in Adults (Krumholz, Neurology 2015) + ILAE 2014 Operational Definition of Epilepsy (Fisher, Epilepsia 2014) + NICE NG217 (2022) Epilepsies + ILAE 2017 Classification (Scheffer, Epilepsia 2017) + MESS (Marson, Lancet 2005) + FIRST Seizure Trial — PMID:25901057
  • Cited evidence (PMID 24730690) — PMID:24730690
  • Cited evidence (PMID 18025394) — PMID:18025394
  • Cited evidence (PMID 15950714) — PMID:15950714
  • Cited evidence (PMID 16545748) — PMID:16545748