Predicting a second seizure after a single unprovoked seizure

Why was this review performed?

A single unprovoked seizure is fairly common, with estimates that up to 3% to 4% of the population will have one by age 85. This translates to approximately one in 25 people having an epileptic seizure during their lifetime. It is therefore of the utmost importance that accurate prognostic data are available so that clinicians can reliably counsel people on the risk of further seizures, and factors that predict the recurrence of seizures and therefore the development of epilepsy.

What is the aim of the review?

The main objective of this review is to provide people presenting with a single seizure, their families, and the clinicians looking after them, with more accurate information relating to the risk of further unprovoked seizures and the development of epilepsy.

The additional objective of this review is to provide people presenting with a single seizure, their families, and the clinicians looking after them, with more accurate information relating to the risk of premature death following an unprovoked seizure.

Key messages

Despite some quite big differences in the design of the studies included in this review, we were able to provide information on the risk of having another seizure at 6 months, 12 months and 24 months.

What was studied in the review?

We searched for relevant studies that had a reliable design and that reported the number of people who had a second seizure after a first unprovoked seizure. We found 58 studies involving 12,160 people. Twenty-six studies involved children only, 16 were adult only and the remaining 16 studies were a combination of children and adults. People had to have been followed up for a minimum of six months and include a minimum number of 30 people.

What were the main results of the review?

We collected the reported second seizure rates at 6 months, 12 months and 24 months. We then combined the data at these three set time points and were able to compare the chances of having a second seizure according to how much time had passed after the first seizure. At six months the chances of having a second event was 27%, whilst it was 36% at one year and finally at two years it was 43%. The chances of having a second seizure are slightly higher in children compared to adults.

How up to date is this review?

The evidence is current to March 2021.

Authors' conclusions: 

Despite the limitations of the data (moderate-certainty of evidence), mainly relating to clinical and methodological heterogeneity we have provided summary estimates for the likely risk of seizure recurrence at six months, one year and two years for both children and adults. This provides information that is likely to be useful for the clinician counselling patients (or their parents) on the probable risk of further seizures in the short-term whilst acknowledging the paucity of long-term recurrence data, particularly beyond 10 years.

Read the full abstract...

Epilepsy is clinically defined as two or more unprovoked epileptic seizures more than 24 hours apart. Given that, a diagnosis of epilepsy can be associated with significant morbidity and mortality, it is imperative that clinicians (and people with seizures and their relatives) have access to accurate and reliable prognostic estimates, to guide clinical practice on the risks of developing further unprovoked seizures (and by definition, a diagnosis of epilepsy) following single unprovoked epileptic seizure.


1. To provide an accurate estimate of the proportion of individuals going on to have further unprovoked seizures at subsequent time points following a single unprovoked epileptic seizure (or cluster of epileptic seizures within a 24-hour period, or a first episode of status epilepticus), of any seizure type (overall prognosis).

2. To evaluate the mortality rate following a first unprovoked epileptic seizure.

Search strategy: 

We searched the following databases on 19 September 2019 and again on 30 March 2021, with no language restrictions.

The Cochrane Register of Studies (CRS Web), MEDLINE Ovid (1946 to March 29, 2021), SCOPUS (1823 onwards),, the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). CRS Web includes randomized or quasi-randomized, controlled trials from PubMed, Embase,, the World Health Organization International Clinical Trials Registry Platform (ICTRP), the Cochrane Central Register of Controlled Trials (CENTRAL), and the Specialized Registers of Cochrane Review Groups including Epilepsy. In MEDLINE (Ovid) the coverage end date always lags a few days behind the search date.

Selection criteria: 

We included studies, both retrospective and prospective, of all age groups (except those in the neonatal period (< 1 month of age)), of people with a single unprovoked seizure, followed up for a minimum of six months, with no upper limit of follow-up, with the study end point being seizure recurrence, death, or loss to follow-up. To be included, studies must have included at least 30 participants.

We excluded studies that involved people with seizures that occur as a result of an acute precipitant or provoking factor, or in close temporal proximity to an acute neurological insult, since these are not considered epileptic in aetiology (acute symptomatic seizures). We also excluded people with situational seizures, such as febrile convulsions.

Data collection and analysis: 

Two review authors conducted the initial screening of titles and abstracts identified through the electronic searches, and removed non-relevant articles. We obtained the full-text articles of all remaining potentially relevant studies, or those whose relevance could not be determined from the abstract alone and two authors independently assessed for eligibility. All disagreements were resolved through discussion with no need to defer to a third review author.

We extracted data from included studies using a data extraction form based on the checklist for critical appraisal and data extraction for systematic reviews of prediction modelling studies (CHARMS).

Two review authors then appraised the included studies, using a standardised approach based on the quality in prognostic studies (QUIPS) tool, which was adapted for overall prognosis (seizure recurrence).

We conducted a meta-analysis using Review Manager 2014, with a random-effects generic inverse variance meta-analysis model, which accounted for any between-study heterogeneity in the prognostic effect. We then summarised the meta-analysis by the pooled estimate (the average prognostic factor effect), its 95% confidence interval (CI), the estimates of I² and Tau² (heterogeneity), and a 95% prediction interval for the prognostic effect in a single population at three various time points, 6 months, 12 months and 24 months. Subgroup analysis was performed according to the ages of the cohorts included; studies involving all ages, studies that recruited adult only and those that were purely paediatric.

Main results: 

Fifty-eight studies (involving 54 cohorts), with a total of 12,160 participants (median 147, range 31 to 1443), met the inclusion criteria for the review. Of the 58 studies, 26 studies were paediatric studies, 16 were adult and the remaining 16 studies were a combination of paediatric and adult populations.

Most included studies had a cohort study design with two case-control studies and one nested case-control study. Thirty-two studies (29 cohorts) reported a prospective longitudinal design whilst 15 studies had a retrospective design whilst the remaining studies were randomised controlled trials.

Nine of the studies included presented mortality data following a first unprovoked seizure. For a mortality study to be included, a proportional mortality ratio (PMR) or a standardised mortality ratio (SMR) had to be given at a specific time point following a first unprovoked seizure.

To be included in the meta-analysis a study had to present clear seizure recurrence data at 6 months, 12 months or 24 months. Forty-six studies were included in the meta-analysis, of which 23 were paediatric, 13 were adult, and 10 were a combination of paediatric and adult populations.

A meta-analysis was performed at three time points; six months, one year and two years for all ages combined, paediatric and adult studies, respectively. We found an estimated overall seizure recurrence of all included studies at six months of 27% (95% CI 24% to 31%), 36% (95% CI 33% to 40%) at one year and 43% (95% CI 37% to 44%) at two years, with slightly lower estimates for adult subgroup analysis and slightly higher estimates for paediatric subgroup analysis. It was not possible to provide a summary estimate of the risk of seizure recurrence beyond these time points as most of the included studies were of short follow-up and too few studies presented recurrence rates at a single time point beyond two years. The evidence presented was found to be of moderate certainty.