Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate®

Evaluation of the first seizure in adults

Steven C Schachter, MD
Section Editor
Paul Garcia, MD
Deputy Editor
April F Eichler, MD, MPH


A seizure is a sudden change in behavior that is the consequence of brain dysfunction:

Epileptic seizures result from electrical hypersynchronization of neuronal networks in the cerebral cortex. Epilepsy is defined when any of the following exist [1]:

At least two unprovoked (or reflex) seizures occurring more than 24 hours apart.

One unprovoked (or reflex) seizures and a probability of further seizures similar to the general recurrence risk after two unprovoked seizures (eg, ≥60 percent), occurring over the next 10 years. This may be the case with remote structural lesions such as stroke, central nervous system infection, or certain types of traumatic brain injury.

Diagnosis of an epilepsy syndrome.


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Dec 2016. | This topic last updated: Fri Nov 11 00:00:00 GMT+00:00 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Fisher RS, Acevedo C, Arzimanoglou A, et al. ILAE official report: a practical clinical definition of epilepsy. Epilepsia 2014; 55:475.
  2. Vossler, DG. Nonepileptic seizures of physiologic origin. J Epilepsy 1995; 8:1.
  3. Alper K, Devinsky O, Perrine K, et al. Psychiatric classification of nonconversion nonepileptic seizures. Arch Neurol 1995; 52:199.
  4. Bortz, JJ. Nonepileptic seizures: issues in differential diagnosis and treatment. CNS Spectrums 1997; 2:20.
  5. Berg AT, Shinnar S. The risk of seizure recurrence following a first unprovoked seizure: a quantitative review. Neurology 1991; 41:965.
  6. Camfield PR, Camfield CS, Dooley JM, et al. Epilepsy after a first unprovoked seizure in childhood. Neurology 1985; 35:1657.
  7. Willmore LJ. Epilepsy emergencies: the first seizure and status epilepticus. Neurology 1998; 51:S34.
  8. Schachter SC. Iatrogenic seizures. Neurol Clin 1998; 16:157.
  9. Schold C, Yarnell PR, Earnest MP. Origin of seizures in elderly patients. JAMA 1977; 238:1177.
  10. Sander JW, Hart YM, Johnson AL, Shorvon SD. National General Practice Study of Epilepsy: newly diagnosed epileptic seizures in a general population. Lancet 1990; 336:1267.
  11. Cleary P, Shorvon S, Tallis R. Late-onset seizures as a predictor of subsequent stroke. Lancet 2004; 363:1184.
  12. Annegers JF, Hauser WA, Coan SP, Rocca WA. A population-based study of seizures after traumatic brain injuries. N Engl J Med 1998; 338:20.
  13. Temkin NR. Antiepileptogenesis and seizure prevention trials with antiepileptic drugs: meta-analysis of controlled trials. Epilepsia 2001; 42:515.
  14. Beghi E, Carpio A, Forsgren L, et al. Recommendation for a definition of acute symptomatic seizure. Epilepsia 2010; 51:671.
  15. Hesdorffer DC, Benn EK, Cascino GD, Hauser WA. Is a first acute symptomatic seizure epilepsy? Mortality and risk for recurrent seizure. Epilepsia 2009; 50:1102.
  16. Fields MC, Labovitz DL, French JA. Hospital-onset seizures: an inpatient study. JAMA Neurol 2013; 70:360.
  17. Riggs JE. Neurologic manifestations of electrolyte disturbances. Neurol Clin 2002; 20:227.
  18. Fisher RS, Harding G, Erba G, et al. Photic- and pattern-induced seizures: a review for the Epilepsy Foundation of America Working Group. Epilepsia 2005; 46:1426.
  19. Pittau F, Tinuper P, Bisulli F, et al. Videopolygraphic and functional MRI study of musicogenic epilepsy. A case report and literature review. Epilepsy Behav 2008; 13:685.
  20. Takada H, Aso K, Watanabe K, et al. Epileptic seizures induced by animated cartoon, "Pocket Monster". Epilepsia 1999; 40:997.
  21. Harding G, Wilkins AJ, Erba G, et al. Photic- and pattern-induced seizures: expert consensus of the Epilepsy Foundation of America Working Group. Epilepsia 2005; 46:1423.
  22. Seri S, Cerquiglini A, Harding GF. Visually induced syncope: a nonepileptic manifestation of visual sensitivity? Neurology 2006; 67:359.
  23. Berg AT, Berkovic SF, Brodie MJ, et al. Revised terminology and concepts for organization of seizures and epilepsies: report of the ILAE Commission on Classification and Terminology, 2005-2009. Epilepsia 2010; 51:676.
  24. Proposal for revised classification of epilepsies and epileptic syndromes. Commission on Classification and Terminology of the International League Against Epilepsy. Epilepsia 1989; 30:389.
  25. Alessi R, Vincentiis S, Rzezak P, Valente KD. Semiology of psychogenic nonepileptic seizures: age-related differences. Epilepsy Behav 2013; 27:292.
  26. Asadi-Pooya AA, Emami M, Emami Y. Ictal injury in psychogenic non-epileptic seizures. Seizure 2014; 23:363.
  27. Theodore WH. The postictal state: effects of age and underlying brain dysfunction. Epilepsy Behav 2010; 19:118.
  28. Gallmetzer P, Leutmezer F, Serles W, et al. Postictal paresis in focal epilepsies--incidence, duration, and causes: a video-EEG monitoring study. Neurology 2004; 62:2160.
  29. Ito M. Neuropsychiatric evaluations of postictal behavioral changes. Epilepsy Behav 2010; 19:134.
  30. Dallos V, Heathfield K. Iatrogenic epilepsy due to antidepressant drugs. Br Med J 1969; 4:80.
  31. Rosati A, Guerrini R, Cimaz R. Lupus, antiphospholipid syndrome and epilepsy: an update. Lupus 2017; 26:3.
  32. Noureldine MH, Harifi G, Berjawi A, et al. Hughes syndrome and epilepsy: when to test for antiphospholipid antibodies? Lupus 2016.
  33. Ottman R, Barker-Cummings C, Leibson CL, et al. Accuracy of family history information on epilepsy and other seizure disorders. Neurology 2011; 76:390.
  34. Brigo F, Storti M, Lochner P, et al. Tongue biting in epileptic seizures and psychogenic events: an evidence-based perspective. Epilepsy Behav 2012; 25:251.
  35. Brigo F, Nardone R, Bongiovanni LG. Value of tongue biting in the differential diagnosis between epileptic seizures and syncope. Seizure 2012; 21:568.
  36. Brigo F, Nardone R, Ausserer H, et al. The diagnostic value of urinary incontinence in the differential diagnosis of seizures. Seizure 2013; 22:85.
  37. Krumholz A, Wiebe S, Gronseth G, et al. Practice Parameter: evaluating an apparent unprovoked first seizure in adults (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Epilepsy Society. Neurology 2007; 69:1996.
  38. Shukla G, Bhatia M, Vivekanandhan S, et al. Serum prolactin levels for differentiation of nonepileptic versus true seizures: limited utility. Epilepsy Behav 2004; 5:517.
  39. Chen DK, So YT, Fisher RS, Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Use of serum prolactin in diagnosing epileptic seizures: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology 2005; 65:668.
  40. Willert C, Spitzer C, Kusserow S, Runge U. Serum neuron-specific enolase, prolactin, and creatine kinase after epileptic and psychogenic non-epileptic seizures. Acta Neurol Scand 2004; 109:318.
  41. Pritchard PB 3rd, Wannamaker BB, Sagel J, Daniel CM. Serum prolactin and cortisol levels in evaluation of pseudoepileptic seizures. Ann Neurol 1985; 18:87.
  42. Shah AK, Shein N, Fuerst D, et al. Peripheral WBC count and serum prolactin level in various seizure types and nonepileptic events. Epilepsia 2001; 42:1472.
  43. Hung TY, Chen CC, Wang TL, et al. Transient hyperammonemia in seizures: a prospective study. Epilepsia 2011; 52:2043.
  44. Wyllie E, Lueders H, Pippenger C, VanLente F. Postictal serum creatine kinase in the diagnosis of seizure disorders. Arch Neurol 1985; 42:123.
  45. Petramfar P, Yaghoobi E, Nemati R, Asadi-Pooya AA. Serum creatine phosphokinase is helpful in distinguishing generalized tonic-clonic seizures from psychogenic nonepileptic seizures and vasovagal syncope. Epilepsy Behav 2009; 15:330.
  46. Angus-Leppan H. First seizures in adults. BMJ 2014; 348:g2470.
  47. Fountain NB, Van Ness PC, Swain-Eng R, et al. Quality improvement in neurology: AAN epilepsy quality measures: Report of the Quality Measurement and Reporting Subcommittee of the American Academy of Neurology. Neurology 2011; 76:94.
  48. van Donselaar CA, Schimsheimer RJ, Geerts AT, Declerck AC. Value of the electroencephalogram in adult patients with untreated idiopathic first seizures. Arch Neurol 1992; 49:231.
  49. Shinnar S, Kang H, Berg AT, et al. EEG abnormalities in children with a first unprovoked seizure. Epilepsia 1994; 35:471.
  50. Leach JP, Stephen LJ, Salveta C, Brodie MJ. Which electroencephalography (EEG) for epilepsy? The relative usefulness of different EEG protocols in patients with possible epilepsy. J Neurol Neurosurg Psychiatry 2006; 77:1040.
  51. Harden CL, Huff JS, Schwartz TH, et al. Reassessment: neuroimaging in the emergency patient presenting with seizure (an evidence-based review): report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology 2007; 69:1772.
  52. Hakami T, McIntosh A, Todaro M, et al. MRI-identified pathology in adults with new-onset seizures. Neurology 2013; 81:920.
  53. Ramirez-Lassepas M, Cipolle RJ, Morillo LR, Gumnit RJ. Value of computed tomographic scan in the evaluation of adult patients after their first seizure. Ann Neurol 1984; 15:536.
  54. Betting LE, Mory SB, Lopes-Cendes I, et al. MRI reveals structural abnormalities in patients with idiopathic generalized epilepsy. Neurology 2006; 67:848.
  55. Krauss GL, Ampaw L, Krumholz A. Individual state driving restrictions for people with epilepsy in the US. Neurology 2001; 57:1780.