The patient with an apparent first seizure presents a diagnostic and therapeutic challenge to the emergency department or primary care physician. Proper management of these patients requires a systematic diagnostic evaluation and assessment of the risks and benefits of treatment. Such an assessment requires that the following issues be addressed: Was the attack truly a seizure? Was this seizure truly the first seizure for this patient? Why did the seizure occur? Was the seizure a symptom of an acute neurologic or medical illness, a remote neurologic injury, or did the attack occur without evident cause? How extensive (and expensive) should the diagnostic evaluation be? If a cause for the seizure is identified, is direct therapy available or necessary? What is the likelihood of a recurrent attack? Will treatment with anticonvulsant drugs significantly reduce the risk of subsequent seizures? What are the risks of anticonvulsant drug treatment? Is anticonvulsant drug therapy appropriate for this patient at this time? It should be clear from the preceding discussion that definitive answers to such questions are not possible. The clinical data are always incomplete and uncertain and sometimes erroneous. Considerable clinical judgment is always needed. Nonetheless, we can hope that conscientious, systematic assessment will lead to the best possible treatment for each of our patients.