First unprovoked seizure--to treat or not to treat?

It has always been a controversial subject whether or not to treat a patient with first episode of seizure. The actual decision whether or not to treat patients who present with initial seizure must be individualized. It depends on probability of having a recurrence and on the perceived risk/benefit ratio of treatment. In a large majority of patients, it is prudent to defer treatment with antiepileptic drugs until a second episode has occurred, unless it is a remote symptomatic seizure, associated with definite epileptiform abnormalities in EEG or a partial seizure. However, in an occasional patient, treatment may be indicated even after a first seizure; for example, in patients involved in certain occupations like driving or operating dangerous machinery.