First seizures are always challenging for physicians. Determining etiology, risk of recurrence, need for diagnostic electroencephalogram (EEG) or neuroimaging, balancing starting anti-seizure medication (ASM) versus its potential adverse effects, and addressing patient and family concerns about social or emotional impact in lifestyle issues is always demanding.

a narrative review providing information from a database search between January 1970 to November 2020 was conducted, with the following search terms: first seizure, epidemiology, treatment, neuroimaging, electroencephalogram, impact, lifestyle.

Incidence rates of single unprovoked seizures range from 23 to 64.1 /100000/person-years. The risk of recurrence depends on several clinical, etiological, EEG, and neuroimaging findings that should be approached on an individual basis. Initiating ASM is not generally advised, but shall be considered in individual situations. The emotional and social impact of single seizures must not be underestimated. Some interesting clues are pointing out at risks to present or prevent a first seizure.

Presentation of first seizure, diagnostic workup, treatment, and impact should be considered individually based on continuously updated knowledge of treating physicians.

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