How should I approach the management of a patient presenting with new-onset seizures?

Initial management of a patient presenting with new-onset seizures involves urgent referral to a specialist for assessment within two weeks to confirm diagnosis and determine seizure type and epilepsy syndrome, as misdiagnosis occurs in about 25% of cases.

During the acute seizure event, if the seizure is a tonic-clonic seizure lasting less than 5 minutes, provide first aid by protecting the patient from injury, cushioning their head, removing harmful objects, and placing them in the recovery position once the seizure stops. Do not restrain or put anything in their mouth.

If the tonic-clonic seizure lasts more than 5 minutes or if there are multiple seizures within an hour, administer first-line treatment with buccal midazolam or rectal diazepam in the community, or intravenous lorazepam if intravenous access and resuscitation facilities are available, and call for emergency admission.

For focal seizures, protect the patient from injury and observe until full recovery; arrange emergency admission if the seizure lasts more than 5 minutes or urgent medical attention is needed.

After the acute event, investigations such as MRI brain imaging and EEG should be arranged by specialists to identify underlying causes and guide treatment.

Start antiseizure medication only once epilepsy diagnosis is confirmed. Consider starting treatment after a first unprovoked seizure if there are neurological deficits, epileptic activity on EEG, structural brain abnormalities, or if the patient/family consider the risk of recurrence unacceptable.

Develop an individualised antiseizure medication treatment plan considering seizure type, age, sex, comorbidities, medication interactions, and patient preferences, aiming to use monotherapy where possible.

Advise patients and carers on seizure first aid, recognition, and when to seek emergency help. Provide safety-netting information and consider an emergency management plan for prolonged or recurrent seizures.