After a reported first ictal episode, confirmation that indeed a true epileptic seizure has happened and the identification of its cause are mandatory. If confirmed, the risk of recurrence for further seizures should be assessed. However, a first epileptic seizure does not imply the diagnosis of epilepsy. First epileptic seizures may occur in close temporal relationship with acute structural, toxic, infectious or metabolic cerebral damage as acute symptomatic seizures. These have a low risk of recurrence, which is why no permanent anticonvulsive therapy is recommended. If evidence of interictal epileptiform activity on the EEG (electroencephalography) and/or a potential epileptogenic image pathology is present, the diagnosis of epilepsy and thus the indication for anticonvulsive therapy can be made after the first seizure. First epileptic seizures that cannot be classified into either category should not be treated with anticonvulsive medication.