First seizure management: I can see clearly now?

I read with interest the article by Krumholz et al.1 on the management of an unprovoked first seizure and the comments that followed, especially the one by Cole and Cascino,2 which focused on treatment guidelines. The authors reported an absolute risk reduction in seizure recurrence of 35% during the first 2 years of treatment, based on the 5 studies that randomly divided the patients to receiving or not receiving treatment after the qualifying seizure. However, it seems that being randomly assigned to one of these treatment options yielded the best chances for the patient to remain seizure-free during this period. Overall, 522 out of 1,600 (33%) patients in the randomized studies had 1–2 years seizure recurrence (tables 1 and 21), while 625 of 1,612 (39%) in the studies where physicians decided whether to recommend treatment, based on their clinical judgment, recurred (table 11; p < 0.001, χ2). This observation, which was not reported in the article, emphasizes the limitations of our current knowledge on the issue of treatment after a first seizure, and the complexity of factors taken into consideration while making treatment recommendations in this situation, other than the seizure prevention itself