Epilepsy and first seizure: the Australian general practice approach

A first seizure is a high-stakes presentation in Australian general practice. Most patients are well on arrival, yet the consultation carries an immediate medico-legal obligation — documenting driving advice — alongside a clinical workup designed to distinguish epileptic seizures from their imitators, initiate appropriate investigation, and facilitate timely specialist referral. The single most valuable diagnostic step is a collateral history from a witness, sought by phone if the person is not present in clinic. The Therapeutic Guidelines (eTG) Neurology and RACGP guidance form the primary clinical framework for Australian GPs; the ILAE 2017 operational classification underpins terminology used in referral letters and neurologist correspondence.

A. Core clinical — the AU general-practice framework

Definitions

The ILAE 2017 framework provides the standard operational definitions used in Australian practice:

• Seizure: transient signs or symptoms caused by abnormal excessive or synchronous neuronal activity in the brain.
• Epilepsy: (a) two or more unprovoked seizures more than 24 hours apart; or (b) one unprovoked seizure with a recurrence risk of 60% or higher over 10 years (for example, a remote symptomatic lesion on MRI or epileptiform EEG abnormalities); or (c) a diagnosis of an epilepsy syndrome.
• Provoked (acute symptomatic) seizure: occurs in close temporal relation to an acute brain insult — stroke within seven days, severe head injury within seven days, alcohol withdrawal within 48 hours, hypoglycaemia, or severe hyponatraemia. A provoked seizure does not constitute epilepsy. Treatment targets the underlying cause.
• Status epilepticus (Trinka et al, ILAE 2015): a seizure lasting five minutes or longer, or recurrent seizures without recovery between events requiring emergency treatment. The five-minute mark is the clinical action point; beyond 30 minutes, risk of permanent neurological sequelae increases substantially.

Epidemiology

Epilepsy affects approximately 150,000–250,000 Australians at any one time. Incidence is bimodal — highest in children under five and again after age 65, where stroke and neurodegenerative aetiology dominate. The lifetime risk of any single seizure is approximately 10%; the lifetime risk of epilepsy is 3–4%. Stroke is now the leading single cause of new-onset epilepsy in adults over 35. Aboriginal and Torres Strait Islander Australians carry a higher burden of epilepsy driven by traumatic brain injury, alcohol-related factors, and barriers to specialist access in remote areas.

Seizure classification (ILAE 2017 operational)

Onset	Awareness	Typical features	Notes
Focal	Aware (formerly simple partial)	Motor (clonic, tonic, automatisms) or non-motor (sensory, cognitive, emotional, autonomic)	May spread to bilateral tonic-clonic
Focal	Impaired awareness (formerly complex partial)	Automatisms (lip-smacking, hand fidgeting), post-ictal confusion	Most common in temporal lobe epilepsy
Generalised	Awareness usually impaired	Tonic-clonic, absence, myoclonic, atonic, tonic	Bilateral from outset
Unknown onset	—	Tonic-clonic, behavioural arrest, epileptic spasms	Re-classify when further information is available

B. Differential diagnosis: distinguishing seizures from mimics

Syncope is the most common seizure mimic encountered in Australian general practice and is frequently misclassified. The table below summarises the key differential diagnoses:

Mimic	Distinguishing features in the history
Vasovagal / orthostatic syncope	Pre-syncopal warning (lightheadedness, nausea, warmth, visual greying), upright posture at onset, loss of consciousness under 30 seconds, rapid full recovery. Brief limb jerks (convulsive syncope) are common and frequently misdiagnosed as tonic-clonic seizure. Lateral tongue bite favours epilepsy; tip bite favours syncope.
Cardiac syncope	Exertional loss of consciousness, supine events, palpitations, family history of sudden cardiac death or channelopathy. ECG is mandatory in all patients — exclude long QT syndrome, Brugada pattern, complete heart block.
Transient ischaemic attack	Negative phenomena (loss of function), older patient, vascular risk factors present, no post-ictal phase.
Migraine with aura	Aura symptoms develop over minutes (slow march), visual scotoma rather than positive phenomena, headache typically follows; no post-ictal confusion.
Panic attack / hyperventilation	Dyspnoea, carpopedal spasm, bilateral paraesthesiae, context of anxiety.
Non-epileptic attack syndrome (NEAS) / functional seizures	Often prolonged (over two minutes), eyes closed throughout (epileptic events usually have eyes open), pelvic thrusting, side-to-side head movement, asynchronous limb movements, apparent awareness despite generalised motor activity, post-ictal tearfulness. NEAS commonly coexists with epilepsy.
Parasomnia / sleep disorders	NREM parasomnias (sleep terrors, sleepwalking) in the first third of the night; REM sleep behaviour disorder in older adults; hypnic jerks at sleep onset.
Metabolic	Hypoglycaemia, severe hyponatraemia, uraemia, hepatic encephalopathy — provoked seizure context.

Taking the seizure history

Always seek a collateral account from a witness — this is the highest-yield single diagnostic step. Document three phases:

• Before: triggers (sleep deprivation, alcohol, illness, flickering lights, missed meals), prodrome, aura character (rising abdominal sensation, déjà vu, unilateral sensory disturbance have high localising value), position at onset.
• During: eye position (open and deviated favours epilepsy; closed favours NEAS or syncope), motor pattern and distribution, incontinence, tongue injury, duration. Witnesses reliably overestimate seizure duration.
• After: speed of recovery (rapid return to normal favours syncope; confusion lasting minutes to hours favours epileptic post-ictal state), Todd paresis, headache, myalgia.

The history should also cover previous febrile convulsions in childhood, head injury (timing and severity), CNS infection or stroke, medications that lower the seizure threshold (tramadol, bupropion, clozapine, fluoroquinolones, theophylline), alcohol and recreational drug use, family history of epilepsy, and contraception and pregnancy status for women of childbearing potential.

C. Investigation strategy and ASM evidence

First-seizure workup

All patients with a suspected first seizure require:

Investigation	Rationale
12-lead ECG (MBS item 11700)	Mandatory — excludes long QT syndrome, Brugada pattern, AV block masquerading as convulsive syncope.
Bloods: FBC, electrolytes, glucose, calcium, magnesium, LFT, CK	Identifies provoked causes and metabolic contributors; CK rises following tonic-clonic seizure. Prolactin is no longer recommended — poor sensitivity and specificity per AAN guidelines.
Alcohol and urine drug screen	In selected patients based on history.
MRI brain (epilepsy protocol) (MBS 63507/63510)	Preferred over CT outside the acute setting. Epilepsy protocol includes thin-slice coronal T1 inversion recovery, FLAIR, and T2 sequences to detect hippocampal sclerosis, focal cortical dysplasia, low-grade tumour, and vascular malformation. CT is appropriate acutely in the emergency department or when MRI is unavailable.
EEG (MBS 11000)	Ideally within 24–48 hours of the event — yield for epileptiform discharges is approximately 30%, declining with delay. Sleep-deprived EEG increases yield. A normal EEG does not exclude epilepsy.

Lumbar puncture is not routine; it is indicated when CNS infection, autoimmune encephalitis, or persistent unexplained altered consciousness is suspected.

When to start an antiseizure medication

Anti-seizure medications are not started routinely after a single unprovoked seizure. The MESS trial (Marson 2005, Lancet) demonstrated that immediate ASM treatment reduces short-term recurrence by approximately 35% relative risk but does not improve long-term remission or quality of life. Starting ASM after a first seizure is appropriate when any of the following high-risk features is present:

• Remote symptomatic lesion on MRI (prior stroke, low-grade tumour, vascular malformation).
• Epileptiform abnormalities on EEG.
• Exclusively nocturnal seizure.
• Status epilepticus as the first event.
• Patient preference after thorough discussion of the 35% two-year recurrence risk and the side-effect and driving implications.

ASM is routinely offered — and epilepsy diagnosed — after two or more unprovoked seizures, or after one seizure with a high recurrence risk.

Antiseizure medication choice

The SANAD II trial (Marson et al, Lancet 2021) is the most informative recent comparative trial for first-line ASM choice in adults:

ASM	First-line for	Key adverse effects	Important cautions
Levetiracetam	Focal and generalised	Irritability, behavioural change, fatigue	Dose reduce in renal impairment; pre-existing psychiatric history warrants monitoring
Lamotrigine	Focal (SANAD II preferred), generalised, pregnancy-preferred	Rash (including Stevens–Johnson — requires slow titration), insomnia	Titration over six or more weeks mandatory; sodium valproate doubles lamotrigine levels
Sodium valproate	Generalised — most efficacious overall; second-line focal	Tremor, weight gain, alopecia, hepatotoxicity, pancreatitis, hyperammonaemia	Avoid in pregnancy and in women of childbearing potential — 10% major malformation rate, neural tube defects, ~9-point IQ reduction in exposed children (NEAD), ~3× autism risk. TGA mandatory pregnancy-prevention programme.
Carbamazepine	Focal	Hyponatraemia, rash, leukopenia, dizziness	Screen for HLA-B*1502 in patients of Han Chinese, Thai, or Malay ancestry before prescribing (Stevens–Johnson risk); strong CYP inducer — multiple drug interactions
Oxcarbazepine	Focal	Hyponatraemia, rash	HLA-B*1502 caution as for carbamazepine
Topiramate	Adjunct; migraine overlap	Cognitive dulling, weight loss, renal calculi, acute angle-closure glaucoma	Cleft palate; teratogenic — avoid in pregnancy potential

All of these are available on the Pharmaceutical Benefits Scheme as Authority Required listings. TGA and the Epilepsy Foundation of Australia recommend maintaining brand consistency for ASMs wherever possible — bioequivalence studies for individual ASMs do not reliably reflect clinical interchangeability, and brand switching has been associated with breakthrough seizures in case reports.

SANAD II confirmed that lamotrigine is non-inferior to levetiracetam for focal epilepsy with lower treatment discontinuation rates. For generalised epilepsy, sodium valproate showed superior seizure control in men, but levetiracetam is the preferred first-line agent in women of childbearing potential.

Valproate teratogenicity — the primary preventable harm in epilepsy care

Tomson et al (Lancet Neurology 2018) quantified major congenital malformation rates across antiepileptic drugs in a large international registry: valproate 10.3%, topiramate 3.9%, phenobarbital 6.5%, versus lamotrigine 2.0% and levetiracetam 2.8%. The NEAD study (Meador et al, NEJM 2009) demonstrated that children exposed to valproate in utero had IQ scores approximately nine points lower at six years than children exposed to lamotrigine, carbamazepine, or phenytoin, with threefold higher rates of autism spectrum disorder at long-term follow-up.

Pre-conception counselling for every woman of childbearing potential with epilepsy is a standard-of-care obligation in Australian general practice. If valproate remains the only effective treatment, a TGA Pregnancy Prevention Programme must be documented with annual structured review. High-dose folate (5 mg daily) from before conception through the end of the first trimester is recommended by the RACGP and RANZCOG.

SUDEP counselling

Sudden Unexpected Death in Epilepsy (SUDEP) affects approximately one in 1,000 patient-years overall, rising to approximately five per 1,000 in drug-resistant epilepsy. Risk is highest in patients with frequent nocturnal generalised tonic-clonic seizures, poor adherence, polysubstance use, and suboptimal seizure control. Australian epilepsy guidelines now regard failure to discuss SUDEP as a quality-of-care deficit. Risk reduction strategies include optimising seizure control, improving adherence, addressing sleep hygiene and alcohol use, and considering seizure detection devices for unsupervised overnight seizures (limited evidence for mortality reduction, but may allow earlier intervention).

D. Australian operations

MBS billing

Item	Indication
23/36/44	Standard GP consultation (Level B/C/D)
11700 / 11707	ECG with full report / interpretation only
63507 / 63510	MRI brain with neurologist or paediatrician referral
11000 / 11003	Standard EEG / sleep-deprived or ambulatory EEG
110 / 116	Neurologist consultation
721 / 723	GP Management Plan and Team Care Arrangements — for chronic epilepsy (six months or longer)
2715 / 2717	Mental health treatment plan — for comorbid depression or anxiety

All MBS items are verified via MBS Online; check the current schedule for current rebate values and any changed access rules.

PBS

Levetiracetam, lamotrigine, sodium valproate, and carbamazepine are all listed on the Pharmaceutical Benefits Scheme as Authority Required (most are Streamlined Authority). Second-line and adjunct agents (lacosamide, perampanel, clobazam) generally require specialist initiation or co-prescription. Cannabidiol (Epidyolex) is PBS-listed under Authority Required for Lennox–Gastaut syndrome, Dravet syndrome, and tuberous sclerosis complex — specialist initiation is required. Safety Net thresholds apply for long-term ASM users.

Austroads driving standards

The Austroads Assessing Fitness to Drive 2022 standards apply nationally. GPs are legally and professionally obligated to counsel every patient at every relevant visit, and to document this conversation in the medical record.

Clinical scenario	Private licence	Commercial licence
First unprovoked seizure	6 months seizure-free	5 years seizure-free off all ASMs
Established epilepsy	12 months seizure-free	10 years seizure-free off all ASMs
Provoked / acute symptomatic seizure	6 months (most causes)	Case-by-case
Sleep-only seizures (≥2 years exclusively nocturnal)	Conditional licence possible	Not eligible
Breakthrough seizure or status epilepticus	12 months from event	Recalculated

The patient carries the legal obligation to notify their state road licensing authority. The GP may — and in circumstances where the patient refuses and continues driving, in most states should — notify the authority under qualified privilege provisions. State-specific rules apply; document any direct notification.

Referral pathways

First-seizure rapid-access clinics operate at most major Australian tertiary centres and typically provide a combined neurology, EEG, and MRI assessment within two weeks. Indications for urgent specialist referral include: diagnostic uncertainty; high-risk features warranting early ASM consideration; pregnancy with epilepsy; or any child with a first non-febrile seizure. Drug-resistant epilepsy (failure of two appropriately chosen and dosed ASMs) warrants referral to a tertiary epilepsy centre for consideration of video-EEG, surgical workup, or advanced therapies.

E. Special populations

Pregnancy and preconception

Women with epilepsy planning pregnancy require structured preconception counselling addressing: ASM teratogenicity (switch away from valproate and topiramate before conception wherever possible); high-dose folate (5 mg daily from before conception); contraception interactions (enzyme-inducing ASMs reduce efficacy of combined oral contraceptives — use copper IUD, levonorgestrel IUD, or depot medroxyprogesterone); and ongoing monitoring (lamotrigine levels fall during pregnancy, requiring dose adjustment and therapeutic drug monitoring). The Australian Pregnancy Register for Antiepileptic Drugs (APR) captures prospective safety data and enrolment should be encouraged for all pregnant women taking ASMs.

Older adults

New-onset epilepsy in adults over 65 is most commonly vascular in aetiology. Polypharmacy and reduced renal clearance affect ASM dosing — levetiracetam dose reduction is required in renal impairment; carbamazepine carries high risk of hyponatraemia. Older adults are at higher risk of falls during post-ictal states and from drug-related dizziness. Driving must be discussed explicitly; cognitive impairment may affect the patient’s capacity to self-report.

Aboriginal and Torres Strait Islander peoples

Epilepsy prevalence is higher in Aboriginal and Torres Strait Islander communities due to elevated rates of traumatic brain injury, alcohol-use related seizures, and inadequate access to specialist neurology in remote and regional areas. Cultural safety in clinical encounters — yarning approach, engaging family members as appropriate, and awareness of the potential impact of Sorry Business on follow-up — is essential. Telehealth neurology services and RFDS-linked specialist networks provide options where in-person access is limited.

Children and adolescents

Childhood epilepsy syndromes (juvenile myoclonic epilepsy, childhood absence epilepsy, benign epilepsy with centrotemporal spikes) have distinct natural histories and ASM choices. Febrile convulsions are not epilepsy; brief simple febrile convulsions carry a lifetime epilepsy risk of approximately 2–3% — marginally above the general population. Any child with a first afebrile seizure should be referred to a paediatric neurologist. Valproate carries additional concern in adolescent females — initiation should be specialist-led with documented discussion of teratogenicity risk.

When to escalate

• Status epilepticus — call ambulance immediately for any seizure lasting five minutes or longer; do not wait.
• First seizure with focal neurological deficit, signs of raised intracranial pressure, or severe headache — emergency department same day; possible intracranial mass or haemorrhage.
• Suspected CNS infection (fever, meningism, immunocompromise) — emergency department immediately.
• Pregnancy with an uncontrolled first seizure or new-onset epilepsy — urgent neurologist review.
• Drug-resistant epilepsy (failure of two adequate ASM trials) — tertiary epilepsy clinic for video-EEG and surgical assessment.
• SUDEP risk optimisation in drug-resistant epilepsy — tertiary epilepsy clinic.
• Diagnostic uncertainty between epilepsy and NEAS — video-EEG is the gold standard; refer to a specialist for ambulatory or inpatient video-EEG.

What this article is and is not

This article is a general-practice clinical reference written for Australian GPs and registrars. It summarises evidence-based management principles aligned with the RACGP, eTG Neurology, Austroads, and ILAE frameworks as at the date of last review. It is not a substitute for individualised clinical judgement, specialist consultation, or the most current published guidelines — all of which the treating clinician must assess directly. Medication information, MBS item numbers, and PBS listings change regularly; verify current details via MBS Online and the PBS website at the time of prescribing. Nothing in this article constitutes legal advice regarding mandatory reporting obligations; state-specific provisions should be checked with the relevant licensing authority or medical defence organisation.

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Sources cited

1. RACGP — Red Book: Preventive activities in general practice (2024)
2. Therapeutic Guidelines (eTG) — Neurology: Epilepsy and seizures (accessed 2026)
3. Austroads — Assessing Fitness to Drive 2022 (Epilepsy and seizures)
4. Epilepsy Foundation of Australia — Australian Clinical Practice Guidelines (2024)
5. Epilepsy Action Australia — Patient resources and seizure first aid
6. Fisher et al — ILAE operational classification of seizure types (Epilepsia 2017)
7. Trinka et al — ILAE definition and classification of status epilepticus (Epilepsia 2015)
8. Marson et al — SANAD II: effectiveness of antiepileptic drugs (Lancet 2021)
9. Tomson et al — Comparative risk of major congenital malformations with eight antiepileptic drugs (Lancet Neurology 2018)
10. Meador et al — NEAD Study: cognitive function in children exposed in utero to antiepileptic drugs (NEJM 2009)
11. NICE NG217 — Epilepsies in children, young people and adults (2022, updated 2024)
12. Pharmaceutical Benefits Scheme (PBS) — Antiepileptic drugs (Authority Required listings, accessed 2026)
13. MBS Online — ECG, neurology, EEG and MRI brain items (accessed 2026)