Neurologists debate whether treatment is needed for the first non-induced seizure or whether to wait until after the second seizure to begin treatment. Both physicians and patients need to balance the possible effects of the diagnosis, including the ability to drive, work, the risk of causing another seizure, causing physical or neurological damage, or even death. The annual incidence of non-induced seizures in the United States is approximately 150,000. Members of the guideline editorial board conducted a literature review that included 47 publications and graded them according to an evidence-based medical approach, into Class I and Class II studies. They classified nonprovoked epilepsy into two broad categories: epilepsy of unknown etiology or epilepsy associated with known brain injury or neurological disease; and identified two Class I prognostic studies and eight Class II studies that were designed to address the likelihood of seizure recurrence in patients with first nonprovoked seizures. The analysis showed a progressive increase in the cumulative recurrence rate of epilepsy over time, with the highest rates over 1-2 years and even higher over 1 year, e.g., 32% at 1 year and 46% cumulatively over 5 years. The risk of seizure recurrence doubles in certain circumstances. For example, the 1-5 year recurrence rate in patients with previous cranial injury is 2.55 times higher than in patients with epilepsy of unknown etiology. Strong evidence suggests that the presence of epileptic signs in the EEG is associated with an increased risk of recurrence, with the 1-5 year risk of recurrence being 2.16 times higher in patients with an abnormal EEG than in those with a normal EEG. Moderately strong evidence also showed some factors associated with recurrence, including abnormal cranial imaging and nocturnal seizures, with risk ratios of 2.44 and 2.1, respectively. Professor French said, “If the seizures are not focal, the EEG is completely normal, and the MRI is completely normal, then the risk of recurrence decreases to 20%-25%. -25 percent.” Most people would accept a risk of 25%, but some still feel it is too high. She notes that drug toxicity has decreased compared to the past, and drug tolerability has improved dramatically. But unfortunately, these newer antiepileptic drugs still don’t treat the underlying condition, only control the symptoms. This guideline shows moderately strong evidence that starting treatment immediately after the first non-induced seizure reduces the risk of recurrent seizures within 2 years. In a pooled 2-year data, the absolute risk of seizure recurrence was reduced by 35% in patients treated with an immediate AED compared with delayed AED treatment. In terms of long-term prognosis for epilepsy beyond 3 years, the guidelines suggest that immediate initiation of AED therapy may not significantly improve long-term sustained remission of epilepsy compared with delaying treatment until the second seizure. A controlled Class II study comparing immediate initiation of treatment with delayed treatment found no significant difference in quality of life over 2 years. The new guideline comes at a time when the new definition of epilepsy is changing, as the International League Against Epilepsy (ILAE) has suggested that the definition of epilepsy could be relaxed to include patients with a first unprovoked seizure with a >60% risk of recurrence over 10 years. Many clinicians believe that a single seizure is not epilepsy and therefore does not require treatment.” According to the guidelines, the incidence of adverse events after treatment with a single ED in patients with a first unprovoked seizure is about 7-31%. These adverse events are mild in magnitude and reversible when the dose is reduced or when switching to another AED. These drugs include phenytoin, phenobarbital, carbamazepine, valproic acid, and lamotrigine. The authors noted that the new AEDs had fewer adverse events and were different from those of the previous drugs. The authors also stress the importance of patients knowing when they need AED therapy and the risk of AED discontinuation. Professor Krumboltz said that the new guidelines need to be disseminated among all physicians, including general practitioners and emergency physicians, as the neurologist is not necessarily the first physician to see the patient, and Professor French emphasized that the first seizure may not be a convulsive seizure, but may be a confusion or sensory abnormality that is easily missed. AES President Professor Kayal added that the terminology of AEDs should be noted. The medications that people with epilepsy take should be called “anticonvulsants” rather than “antiepileptic drugs”. These medications do not fundamentally change the epilepsy or its underlying cause, and they do not change the percentage of patients who do not respond to medication, which ultimately fails in about 30% of patients. Therefore, a great need in the field of epilepsy is the development of disease-modifying therapeutics.