Epilepsia, 49(Suppl.
1):40–44, 2008
SUPPLEMENT - MANAGEMENT OF A FIRST SEIZURE
Special considerations for a first seizure in childhood
and adolescence
Peter Camfield and Carol Camfield
Department of Pediatrics, Dalhousie University and the IWK Health Centre, Halifax, Nova Scotia, Canada
SUMMARY
Children with a first unprovoked seizure almost al-
ways present with a convulsive seizure. The differ-
ential diagnosis includes many paroxysmal events,
especially convulsive syncope but even with a good
history; there is often uncertainty that cannot be
eliminated by investigations. In general, an EEG
and MRI are indicated with other investigations
determined on a case-by-case basis. Epilepsy syn-
drome identification may be very valuable. Cur-
This paper focuses on children who present to the health
care system with a first, unprovoked seizure and no previ-
ous seizures. Almost all of these “first” seizures are dra-
matic convulsive attacks—children who experience only
simple partial, complex partial, absence, myoclonus, and
other short seizure types usually come to medical atten-
tion only after multiple attacks. By convulsion we mean
a seizure with generalized or focal clonic activity. Based
on the Nova Scotia population-based childhood epilepsy
study, we estimate that fewer than 50% of children who
will go on to develop epilepsy will present with their first
seizure (Camfield et al., 1985). Of 127 children present-
ing with a “first” seizure to an expert pediatric clinic in
Calgary, Alberta, of the 94 who were diagnosed as hav-
ing an “epilepsy” seizure, nearly one-quarter were discov-
ered to have a history of previous less dramatic seizures
(Hamiwka et al., 2007 in press). These events were either
unrecognized by the family, unclear to the treating physi-
cian or the family did not seek medical attention.
D EFINITION
A controversial issue in pediatric epilepsy is how to cat-
egorize one versus two unprovoked first seizures occurring
Address correspondence to Dr. Peter Camfield, M.D., F.R.C.P.(C),
IWK Health Centre, 5850 University Ave, PO Box 9700, Halifax, Nova
Scotia B3K 6R8, Canada. E-mail: camfield@dal.ca
Blackwell Publishing, Inc.

C International League Against Epilepsy
40
doi: 10.1111/j.1528-1167.2008.01449.x
rent literature allows at least partial answers to
parents’ six most common questions: Will it hap-
pen again? How long do I have to wait for a re-
currence? Could my child die during a recurrence?
Could there be brain damage with a recurrence? If
medication treatment is delayed will there be any
long-term change in the chance of a permanent re-
mission? Now that my child has had a seizure, how
should his/her activities be restricted?
KEY WORDS: First seizure, Child, Adolescent.
within a 24-h period. Investigators from Albert Einstein in
New York have argued that these two events should be con-
sidered as a single seizure (Shinnar et al., 2000). In their
experience with 407 children with a first seizure, the re-
currence risk was the same after one unprovoked seizure
as after 2 provoked seizures within 24 h, as judged by a
10-year follow-up. By contrast, we studied 490 children
with epilepsy characterized by generalized tonic–clonic
or partial seizures with an average follow-up of 7 years
(Camfield & Camfield, 2000). Seventy children had their
first two unprovoked seizures on the “same day” with com-
plete recovery between the seizures, while 420 had their
first two seizures on “different” days. The recurrence risk
(80% and 81%), long-term remission (59% and 56%), and
risk of intractable epilepsy (7% and 8%) were so similar
that we argued that when two first unprovoked seizures oc-
cur on the same day with recovery between the seizures,
then these two seizures should mandate the diagnosis of
epilepsy. The clinical course will be identical to children
with the first two seizures on separate days. The differences
between the New York and Nova Scotia data have not been
explained.
D IFFERENTIAL D IAGNOSIS
The diagnosis of a first seizure is usually straightforward
but the differential diagnosis in children includes a num-
ber of special pediatric disorders—most prominent are pal-
lid syncope and breath holding (Stephenson, 1990). As in

adulthood, a frequent first seizure mimic is syncope with a
reflex anoxic seizure. This is particularly common in ado-
lescent girls.
The history does not always allow a confident diagnosis.
The Dutch group submitted 207 case summaries prepared
by a neurologist of first seizures to a panel of three child
epilepsy experts (van Donsellar et al., 1989). All patients
were then followed for a year. Of 156 considered to have
a definite seizure, 46% had a recurrence, which confirmed
the seizure diagnosis. Of the 54 with a “disputable” first
attack, 14 recurred and the recurrences were convincingly
seizures in 5. The interictal EEG did not assist in the “dis-
putable” group. This group of investigators has advocated
a “watch and wait” approach when the diagnosis is ques-
tionable. We endorse this approach.
I NVESTIGATIONS
A practice parameter of the American Academy of
Neurology has examined the value of investigations for
children with a first afebrile, unprovoked seizure (Hirtz
et al., 2000). This review was based on the available peer-
reviewed literature. The only investigation that reached the
status of a recommendation was an EEG, a test that is of
value for syndrome identification and prediction of recur-
rence. The risk of recurrence is increased by interictal spike
discharge, especially focal spikes. Routine blood work has
no proven benefit.
Since publication of the practice parameter, several stud-
ies have suggested that the yield on MRI for causative ab-
normalities in children with a first seizure is about 20–30%
(Sharma et al., 2003; Shinnar et al., 2001). Abnormalities
that require intervention are considerably fewer, approxi-
mately 1%. Therefore, one can make a reasonable case for
MRI, since occasionally there may be a treatable cause de-
tected or the etiology may have prognostic value or point
to other health concerns.
For selected patients it seems obvious that some blood
tests are indicated—for example, a serum glucose in a child
with diabetes and a seizure.
S YNDROME I DENTIFICATION
When a child presents with a first seizure it is often
possible to diagnose an epilepsy syndrome, a concept that
leads to considerable confusion. Epilepsy is usually de-
fined as two or more unprovoked seizures. After a first un-
provoked seizure in children, the recurrence risk is about
50%; however, after 2 unprovoked seizures, the recurrence
rate is roughly 80% (Camfield et al., 1985; Berg et al.,
1991). So, how can a child with only one seizure be said
to have an “epilepsy” syndrome? A recent suggestion has
been to change the definition of “epilepsy” to a single
seizure plus a tendency for more seizures (Fisher et al.,
2005). This definition is very difficult to use in practice.
41
Special Considerations: Childhood and Adolescence
We prefer to accept the ambiguity and suggest that not ev-
eryone with a defined epilepsy syndrome has or will have
two or more seizures. It is possible to have an epilepsy syn-
drome but not have epilepsy (King et al., 1998; Pohlmann-
Eden et al., 2006).
There may be a tremendous advantage for many chil-
dren with a first seizure to have an epilepsy syndrome
diagnosis. Normal children with a first nocturnal secon-
darily generalized seizure often turn out to have benign
rolandic epilepsy, a diagnosis that can be made by a typi-
cal seizure history, normal neurological and developmental
examination and centrotemporal spikes on EEG with spe-
cial morphology plus an anterior-posterior dipole (Wirrell
et al., 2005). When this epilepsy syndrome is diagnosed
after a first seizure, it is possible to counsel parents that
recurrences are likely to be during sleep and that the long-
range prognosis is virtually always favorable. This disorder
vanishes in adolescence and AED treatment is often not
needed.
Likewise, a normal child presenting with a noctur-
nal prolonged focal seizure without convulsive features
but with eye deviation and vomiting can be confidently
diagnosed as having Panayotopoulos syndrome, if the
EEG shows occipital spike waves (Panayotopoulus, 1999).
Again, the prognosis is excellent, even if there are recurrent
seizures.
We are somewhat less sure of the value of a diag-
nosis of primary generalized epilepsy, when a normal
child presents with a first generalized tonic-clonic seizure
and generalized spike-wave on EEG. If the EEG shows
photosensitivity and the seizure seemed to be provoked
by flashing lights then a syndrome diagnosis of idiopathic
generalized epilepsy (IGE) with photosensitivity has con-
siderable value in avoiding possible seizure triggers.
The diagnosis of the syndromes of cryptogenic partial
epilepsy or symptomatic partial epilepsy are of less use af-
ter a first unprovoked seizure, except to focus the clinician
on a specific area of the MRI scan. Although there are fre-
quent MRI abnormalities in such children, most do not lead
to direct intervention. It is still unclear how imaging find-
ings impact on the recurrence risk, although it is tempting
to assume that an MRI lesion increases the risk of recur-
rence.
Q UESTIONS P OSED BY PARENTS
AFTER A F IRST S EIZURE
Following a child’s first seizure parents (and often the
child) usually have six major questions—Will it happen
again? How long do I have to wait for a recurrence? Could
my child die during a recurrence? Could there be brain
damage with a recurrence? If I choose to delay medication
treatment will there be any long-term change in the chance
of a permanent remission? Now that my child has had a
seizure, how should his/her activities be restricted?
Epilepsia, 49(Suppl. 1):40–44, 2008
doi: 10.1111/j.1528-1167.2008.01449.x
42
P. Camfield and C. Camfield
1. Will it happen again?
The recurrence risk after a first unprovoked seizure in
childhood is essentially the same as in adulthood and fac-
tors that increase the likelihood of recurrence are very sim-
ilar (Camfield et al., 1985; Berg & Shinnar, 1991). Risk
is increased by focal versus generalized seizures, by pres-
ence of spike discharge on EEG and by the presence of
concomitant neurological deficits. Children with none of
these factors have approximately a 20% chance of recur-
rence and children with all of these factors have about an
80% risk of recurrence (Camfield et al., 1985). While these
differences are statistically robust, it is not possible to an-
swer this question with a definitive “yes” or “no.” In any
case, parents should understand appropriate first aid and
have a plan in place for medical attention should there be a
recurrence.
2. How long might it be before we can be sure that
our child will not have a recurrence?
Again, the data for children are similar to adults. In the
Nova Scotia series of 168 children with a first seizure, 70%
of recurrences were within 6 months of the first seizure,
77% by 1 year, and 90% by 2 years (Camfield et al., 1985).
In the series of 407 children from the Bronx with a first
unprovoked seizure, 53% of recurrences were by 6 months
and 88% by 2 years (Shinnar et al., 2000). The answer to
this question is that recurrences may be delayed for 2 years
or more, but most recurrences are within 6 months of the
first seizure.
3. Could my child die during a recurrence?
Perceptions of parents witnessing a first unprovoked
seizure have not been directly reported, although it is likely
that they are similar to the reactions of parents witnessing
a first febrile seizure. During a first febrile seizure almost
all parents indicate that they thought their child was dying
(Rutter & Metcalfe, 1978). After a first afebrile seizure the
fear of death during a seizure may be further increased by
information about SUDEP. The risk of death during a first
recurrent seizure has not been reported; however, children
with established epilepsy have a tiny risk of SUDEP. Three
large studies have addressed this issue. In Nova Scotia, 692
children with epilepsy were followed for about 20 years
(Camfield et al., 2002a). There were 26 deaths, 1 from sta-
tus and only 1 from SUDEP when she was 22 years of
age. In the Dutch study of childhood epilepsy, 472 chil-
dren with epilepsy were followed for 5 years with 9 deaths
(Callenbach et al., 2001). None of the deaths were related
to seizures and there were no cases of SUDEP. In the Con-
necticut study, 613 children were followed for a median of
7.8 years (Berg et al., 2004). Of the 13 deaths, two were re-
lated to seizures—one from status and one SUDEP. There-
fore, this question can be confidently answered—the risk
of a child dying during a recurrent seizure is miniscule.
Epilepsia, 49(Suppl. 1):40–44, 2008
doi: 10.1111/j.1528-1167.2008.01449.x
4. Could there be brain damage with a recurrence?
There are little data about brain damage in studies of
first seizures and recurrences; however, a larger literature
addresses this issue for children with established epilepsy.
It is clear that children with epilepsy have high rates of
cognitive deficits before the first seizure ever occurs. The
critical question is whether they show worsening deficits
with additional seizures. Austin compared 98 children
with epilepsy to 96 children with asthma over a 4-year
period (Austin et al., 2000). As expected, the children
with epilepsy had less satisfactory performance on school
achievement tests at each point in the study compared with
those with asthma but there was no suggestion of deterio-
ration over time, even in those with uncontrolled epilepsy.
Bourgeois and coworkers noted no consistent decline
in IQ in 72 children with newly diagnosed epilepsy
(Bourgeois et al., 1983). Psychology testing within 2 weeks
of diagnosis and then yearly for 4 years showed no change
or improvement in most children. Eleven percent showed
some declined in IQ, but the decline was not related to
seizure number but rather to drug intoxication.
The National Collaborative Perinatal Project (NCPP) as-
certained 55,000 children prenatally and followed them to
7 years of age. There were 98 sibling pairs where one sib-
ling had one or more afebrile seizures and the other did
not (Ellenberg & Nelson, 1978). It is unclear how many of
these children only had a single seizure. Intelligence and
academic testing at 7 years of age showed no difference be-
tween the siblings with seizures and those without. Further-
more, 62 children had not experienced any seizure(s) by
age 4 years when they underwent cognitive testing. Then
between age 4 and 7 years, these same 62 children had
one or more afebrile seizures. Comparisons of the cogni-
tive testing at age 4 with testing at age 7 showed no change.
The answer to this question is that a robust literature
shows that clinically significant brain injury does not re-
sult from a few recurrent unprovoked seizures.
5. If medication treatment is delayed will there be
any long-term change in the chance of a permanent
remission?
Most authorities (Hirtz et al., 2003) recommend no
AED treatment after a first seizure in children, in part
because about half of these children will never have an-
other seizure and in part because there seem to be few
consequences from a second seizure. Few studies directly
address the question of benefit from AED treatment af-
ter a first seizure. In the Nova Scotia study of chil-
dren with established epilepsy, children were prescribed
AED treatment after a variable number of seizures (Cam-
field et al., 1996). This was not a randomized study—
the decision to start AEDs depended on the number of
seizures before diagnosis and a clinical decision on the
part of the family and physician. There were between
20 and 71 children in each group who were treated

after 1, 2, and up to 10 seizures. Eighty-nine started
treatment only after >20 seizures. For a pretreatment num-
ber of seizures <10, the long-term remission rates were
identical. For children with ≥10 seizures before AED treat-
ment, there was a statistically decreased chance of long-
term remission; however, children with ≥10 pretreatment
seizures were much more likely to have complex partial
seizures—a seizure type that we reasoned was intrinsically
less likely to remit. We concluded that waiting for up to 10
seizures before starting AED treatment was not hazardous
from the perspective on long-term remission. There cer-
tainly was no penalty for waiting for a second seizure be-
fore starting AED treatment.
The two main randomized studies of treatment after a
first seizure are outlined elsewhere in this monograph. Nei-
ther the MESS study (Marsden et al., 2005) nor the FIRST
study (Musicco et al., 1997) included large numbers of
children but both studies indicated that early AED treat-
ment reduced early recurrences but over several years the
remission rates were identical in the early and late treat-
ment groups.
We carried out a modest randomized trial of no AED
treatment (n = 14) versus daily carbamazepine (n = 14) af-
ter a first afebrile seizure (Camfield et al., 1989). Over the
next year, statistically fewer children in the carbamazepine
arm had afebrile recurrences but when the children were
followed up about 20 years later, there was no difference
in the long-term remission rate between the two groups
(Camfield et al., 2002b).
There are rare patients for whom treatment after a first
seizures may be reasonable—for example, in association
with cyanotic heart disease; however, for the vast majority,
the answer to this question is a clear “no.” The chance of
remission is not altered by delaying daily AED treatment
after a first seizure.
6. Are there any activities that should be restricted
after a single seizure?
After a first seizure, parents naturally consider restrict-
ing their child’s activities because of concern for body
injury during a recurrent seizure. There is virtually no
literature that allows a rational/evidence-based approach
to restrictions after a first seizure for children and ado-
lescence (ILAE Commission report, 1997). If there are to
be restrictions, they should not be imposed for more than
6–12 months after the first seizure since nearly all re-
currences will have happened by then. It is also relevant
to consider that most seizure-related injuries occur dur-
ing normal daily activities and not during sports or other
special activities.
Here are our suggestions for restrictions after first
seizure, although we freely admit that they are not
evidence-based.
For bathing, we recommend that the child/adolescent
take a shower rather than a bath (no pirouetting taps)
43
Special Considerations: Childhood and Adolescence
(Unglaub et al., 2005), have an adult aware of when they
are in the shower, and be sure not to lock the bathroom
door. For athletic activities, we do not recommend any
changes. Helmet use for bicycling makes sense for all chil-
dren and adults. Swimming should not only be in a super-
vised area but the child should swim with a responsible
buddy. We suggest that the child continue to sleep in his/her
own bed. For those who are found to be photosensitive on
an initial EEG, we recommend moving back as far as possi-
ble when using a video display terminal (VDT) and having
ambient lighting. Tree climbing and other high climbing
activity might be restricted for 3 months. We usually do
not recommend disclosing the first seizure to school au-
thorities because of the risk of stigma and possible further
restrictions from normal school activities.
C ONCLUSIONS
First seizures are disruptive events for a child and fam-
ily. A careful workup including EEG and MRI is usually
warranted. Restrictions on activities should be few and the
treatment strategy of deferral of daily AED treatment until
a recurrence is appropriate and safe.
Disclosure of Conflicts of Interest: The authors have declared no
conflicts of interest.
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