Up to 5% of the population will experience at least 1 nonfebrile seizure at some point during their lifetime. The management of a patient who has had a first-time seizure is driven by the history and physical examination. In almost one-half of these patients, the cause of their seizure is not identified. In general, patients with comorbidities, a focal neurologic examination, or who have not returned to a normal baseline mental status require an extensive diagnostic evaluation including a noncontrast head computed tomography (CT) scan in the emergency department (ED). Adults with a first-time seizure, with no comorbidities, and who have returned to a normal baseline require only serum glucose and electrolyte determination. Women of reproductive age also require a pregnancy test. Patients with a normal neurologic examination, normal laboratory results, and no signs of structural brain disease do not require hospitalization or antiepileptic medications. Initiation of antiepileptic therapy depends on the assessed risk for recurrence, in conjunction with a neurologist consultation.