Treatment issues following a first unprovoked seizure are discussed, using an approach that emphasizes weighing the relative risks and benefits of the therapeutic decisions. The majority of children and adults who present with a first unprovoked seizure will not experience further seizures. Both seizures and the therapies available carry some risk, and optimal patient care requires careful balancing of these risks and benefits. Treatment with antiepileptic drugs reduces recurrence risk but does not alter long-term prognosis. In general, treatment should be deferred until a second seizure has occurred. Whatever the decision, it should be made jointly by the medical providers and the patient and family after careful discussion, including assessment of risk and impact of seizure recurrence. Providing appropriate education and counseling to patients and families may be the most important aspect of treatment of a first unprovoked seizure.