Following their first seizure, many patients see a physician in an emergency room, where a neurologist or epilepsy specialist (particularly at teaching hospitals) is usually available for immediate consultation or in follow-up soon after the patient is discharged. However, many other patients do not receive medical evaluation or care immediately after their first seizure and may be seen in outpatient settings without access to an epilepsy specialist.

This group of quality indicators provides guidance to emergency, primary care and general neurology providers who are "on the front lines" evaluating a patient following their first seizure and in a setting where immediate access to an epilepsy specialist is not available.

These quality indicators suggest specific procedures that should be done to most accurately diagnose the seizure disorder, and they provide insight into situations where referral to an epilepsy expert may be beneficial to the patient. Links at the bottom will take you to pages that discuss topics that are important for patients who have had their first seizure, such as developing a plan to prepare for other seizures and laws about driving.

QI 1. In the initial clinical evaluation of a first seizure, the patient should receive:

  • detailed seizure history (events before, during, and after the seizure)
  • review for predisposing conditions (i.e., stroke, head trauma, drugs/alcohol)
  • physical and neurological examination
  • labs (e.g screening laboratory testing for routine medical assessment)

AND if there is no indication of provocation:

  • an order for an EEG
  • an order for neuroimaging (MRI preferred) or rationale for not ordering


  • Referral to higher level of epilepsy specialty care


QI 2. At the time of initial seizure evaluation, the patient should receive information on driving restrictions, safety and injury prevention.


QI 3. IF the individual with a first unprovoked seizure has any of the following:

  • a neurological deficit
  • an EEG which shows unequivocal epileptiform activity
  • the individual and/or their caregivers consider the risk of having a further seizure more detrimental than a trial of AED treatment (e.g. employment or driving issues)
  • brain imaging shows a structural abnormality
  • Age over 60 years

THEN benefits and risks of AED treatment should be described and AED treatment offered, or reasons for not prescribing should be documented.


QI = Quality Indicator
Primary = Items that were rated as both valid and necessary indicators are primary quality indicators.

For more information:

Authored By: 
Mary Jo V. Pugh PhD RN
Steven C. Schachter MD
Authored Date: