First Seizure Clinic, Differential Diagnosis

An individual presenting with a first seizure often generates diagnostic ambiguity and therapeutic uncertainty. While some have clear indicators of epilepsy, such as recurrence, interictal epileptic discharges on EEG, or structural abnormalities on MRI, others present with normal investigations, an ambiguous history, or significant differential diagnoses. These include syncope and psychogenic non-epileptic seizures, also known as functional dissociative seizures. There is a need for a structured approach when evaluating first seizure presentations, involving detailed history-taking, focused neurological and cardiac investigations, and careful consideration of seizure mimics. Risk stratification is essential in deciding whether to initiate antiseizure medication. Communication and psychosocial support are pivotal to individual engagement and safety. It is vital to recognise the medical and emotional dimensions of a first seizure diagnosis and to adopt a multidisciplinary, person-centred model of care.