This subject has always been controversial as scholars usually differ in their practices of treating or not treating the first seizure. In general, about 60 % of the patients who had their first seizure will never have another one. In this case, it is appropriate to give the facts to the patient and let them make their decisions. If the patient prefers not to be treated and understands the risk of receiving no treatment, it is perfectly acceptable not to treat. Some patients will insist on being treated since they do not want to risk another seizure. In this case, treatment is offered for these patients provided that they understand the seizure recurrence risk is decreased but not necessarily eliminated with treatment. After an acute or remote symptomatic (cerebral insult) seizure in a clinically unstable patient, treatment is usually indicated without waiting for a second seizure. Selecting an appropriate antiepileptic (AED) is quite challenging task in most cases. This is due to the presence of multiple AED options and very little predictability of good response. In addition, efficacy and tolerability of AEDs may strongly differ among individuals.

There are several available factors that could help us make an educated decision of what AED would be best to start with. The spectrum of a particular AED (narrow or broad) is one of these factors (Table 15.4). In general, narrow spectrum AEDs are reserved for seizures with known. When seizure classification is unclear, it is wiser to initiate a broad spectrum agent AED. The reason for this approach is that most narrow spectrum AEDs will not benefit patients with generalized-onset seizures or generalized epilepsies. On the contrary, some narrow spectrum AEDs could cause worsening of seizures if given to a patient with generalized-onset seizures (see Table 15.4).

Mechanism of action (MOA) is another factor that may influence the selection of an AED (Table 15.5). However, the role of MOA is very limited, and the existing data do not support consideration of MOA as a major criterion in choosing an AED. Many AEDs have multiple MOAs, and some have unknown MOAs. This makes it even more difficult to make a judgment based on MOA alone [5, 6]. According to a study by Deckers CL et al., there is some evidence showing that AED polytherapy based on MOA may enhance effectiveness. In particular, combining a sodium channel blocker with a drug enhancing GABAergic inhibitor could be an advantageous combination. Combining two GABA mimetic drugs or combining an AMPA antagonist with an NMDA antagonist may enhance efficacy, but tolerability may be reduced with this combination.