Whether to begin an AED after a first seizure depends on the risks of further seizures, of seizure related injury, psychological distress, loss of employment and loss of driving privileges. Alternatively, the risk of adverse effects from exposure to AEDs must be considered, as well as the likelihood that medication will be effective. Since these variables differ for each patient, the decision is individualized. For example, patients with simple partial seizures are not at risk for physical injury and can usually continue to drive. However, a GTCS may cause injury, be psychologically devastating, and, in most states, will eliminate the possibility of driving for 6 months to as long as a year. Other relevant considerations include whether the seizure was nocturnal and whether it was provoked, i.e. by sleep deprivation, alcohol’or concurrent illness.
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Given the above caveats, most patients should not be treated after a first seizure. Some epilepsy syndromes, such as absence and myoclonic seizures, are essentially certain to recur. For the majority of first seizures, however, the risk of recurrence is low. In adults, the risk of a second seizure ranges from 30 to 60% with highest risk for patients with an abnormal EEG and a remote symptomatic etiology. Most seizures recur within the first. In children, the risk of recurrence within 2 years is 35-50% with the highest risk in children who are neurologically abnormal, have complex partial seizures and abnormal EEGs. After the second seizure, the risk of recurrence rises to 80 to 90%. Several studies suggest that AED treatment does not alter the risk of recurrence.
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When to Stop AEDs

Many patients who have been seizure free for 2 to 5 years can be successfully withdrawn from AEDs. The benefits associated with discontinuation of AEDs must be weighed against the probability that a seizure will occur and the potential adverse consequences of having a seizure. As many as 75% of children who have been seizure free for two years can be successfully withdrawn. Adults are more likely to relapse than children. In adults, relapse occurs in 26-63% with most relapses within one to two years after medication withdrawal. Predictors of relapse include an abnormal EEG prior to or during medication withdrawal, abnormal neurological exam, mental retardation and frequent seizures prior to entering remission. In children, a normal neurological examination, a normal or improved EEG, and early age of onset of seizures are associated with a lower incidence of relapse after medication withdrawal. Successful AED withdrawal in adults is more likely after a longer seizure free period, when seizures have been relatively easy to control seizures (low number of drugs and low serum levels) and when the patient does not have a history of tonic clonic seizures (Medical Research Council, 1991).
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Medication withdrawal should not proceed faster than a 20% dose reduction every five half lives unless there is a pressing need for more rapid discontinuation. The slower withdrawal is recommended because of the risk of withdrawal seizures with rapid medication elimination. These withdrawal seizures are a particular problem with barbiturates and benzodiazepines, which may require withdrawal over a period of months. Withdrawal seizures do not mean that the medication was necessary for control of the epileptic condition.