Acute symptomatic seizures (ASS) occur at the time or in close temporal association with a documented systemic or brain insult and are a common cause for seeking an emergency neurological opinion. The major issues involved in their management are the diagnosis and treatment of the underlying cause, whether seizures should be treated or not, the choice of anti-epileptic drug (AED) and the duration of AED treatment. These decisions are not straightforward and currently no clear guidelines exist to guide management in this area. We outline our current practice which is based on the evidence available on risks of seizure recurrence, and on our own experience. Most ASS only need short term therapy (up to 3 months) if there is complete recovery from the acute insult. Patients with residual structural brain abnormalities with focal neurological deficit and/or MRI changes need long term prophylactic treatment. We make suggestions for minimum duration of treatment for ASS associated with some common conditions, including—subarachnoid and intracerebral haemorrhage—1 year; ischaemic stroke and venous sinus thrombosis—1 year; mild to moderate head injury—acute seizure control only; severe head injury—2 years; metabolic and toxic disorders (including alcohol withdrawal)—correction of underlying cause only; meningoencephalitis with complete recovery and normal MRI—3 months, residual focal deficit and/or MRI changes—2 years; cerebral abscess, tuberculoma—2 years; parasitic granuloma—if completely resolved with normal MRI—3 months, if persistent/calcified—2 years.