Treatment decisions for patients with a first seizure

Here is a guideline synopsis published in JAMA. From the article:

Major recommendations Whether to initiate immediate antiepileptic drug (AED) treatment after a first seizure should be based on individualized assessments that weigh the risk of recurrence against the adverse effects of AED therapy, a consideration of the preferences of an educated patient, and the advice that immediate treatment will not improve the long-term prognosis for seizure remission but will reduce the risk of seizures over the subsequent 2 years…

The new guideline emphasizes that clinicians should weigh the individualized risk of seizure recurrence against the adverse effects of AEDs and consider the preferences of patients. For instance, the risk of seizure recurrence in a patient with normal electroencephalogram and brain magnetic resonance imaging results is relatively low at approximately 25% over the next 2 years.8 While some patients may accept the 25% risk, others may consider it too high. Regardless, patients should be advised that immediate treatment may not improve the long-term prognosis for seizure remission but will reduce seizure risk over the next 2 years. Despite avoiding explicit “to treat or not to treat” recommendations, most of the guideline recommendations conform to current clinical practices. States vary widely in driver licensing requirements for patients with epilepsy (https://www.epilepsy.com/driving-laws), as do requirements for physicians to notify state authorities, complicating the provision of accurate instructions to patients.