Driving restrictions for people with seizures and epilepsy

INTRODUCTION AND OVERVIEW — 

While much remains uncertain and controversial about driving and epilepsy, it is generally agreed that:

●People with uncontrolled epilepsy who drive are at risk for a motor vehicle crash with resulting property damage as well as injury or death to themselves and others.

●For many adults, restrictions on driving place severe limitations on their ability to participate in school, employment, and social activities and therefore significantly diminish independence and quality of life.

These statements represent the conflict that this issue poses between the interests of public health and safety versus the promotion of opportunities and optimal quality of life for people with epilepsy. When asked about the impact of epilepsy on their quality of life, people list driving as their top concern [1,2]. Current regulations and guidelines try to balance these potentially conflicting goals.

Driving restrictions for people with epilepsy date back to the first issuance of driver's licenses, when patients with epilepsy were essentially banned from driving [3]. With the development of effective antiseizure medications, and the recognition that many people with epilepsy were well controlled and therefore at low risk for seizures while driving, laws have been successively revised to relax this total restriction.

However, the basis for deciding which people with epilepsy are safe to drive is supported by somewhat limited evidence. As a result, regulations vary considerably in different states and countries, and there is a lack of consensus even among experts.

Here we discuss the issues involving driving and epilepsy and offer guidance to clinicians and others involved. We emphasize that clinicians must be aware of and comply with the regulations in the state or country in which they practice, inform and educate people with epilepsy and their families or other caregivers about risks and legal obligations, and provide guidance to promote optimal quality of life for people with epilepsy while assuring public safety.

MAGNITUDE OF RISK — 

The contribution of epilepsy to the burden of motor vehicle crashes is not entirely certain.

Risk of crash with seizures — While data vary, it is accepted that the risk of a motor vehicle crash is increased for people with epilepsy [4,5]. From population statistics and survey data, it is estimated that 0.1 to 1.0 percent of all crashes are attributable to seizures [6,7]. Estimates of the relative risk of a motor vehicle crash in a person with epilepsy compared with other drivers range from 1.0 to 2.0 [4,8-10]. One study, which analyzed death certificate data, determined that seizures caused 0.2 percent of motor vehicle fatalities [11]. In this study, the estimated rate of fatal crashes for patients with seizures (8.6 per 100,000) was actually lower than that reported in the total population (22 per 100,000). Also, the rate of fatal crashes caused by alcohol use was eight times greater than for crashes caused by seizures.

These and other studies suggest that for persons with epilepsy, the risk of a motor vehicle crash is similar or slightly higher than in people with other medical conditions such as cardiovascular disease and diabetes and compares favorably with risk of crash in other conditions such as sleep apnea, alcohol use disorder, dementia, cellular telephone use, and age under 25 years [4,5,12].

However, these data do not support a conclusion that driving restrictions for persons with epilepsy are always unfairly discriminatory. One must consider that data on epilepsy and motor vehicle crash risk are collected under current driving restrictions. While adherence is imperfect, driving regulations almost certainly do limit driving by persons with epilepsy and thereby lower crash rates compared with what they might be if all persons with epilepsy drove unrestricted.

It is also possible that available statistics underestimate the number of seizure-related accidents. It is not always obvious that a seizure has caused a crash. People with seizures who are involved in a crash may not report their condition for fear of liability and loss of driving license. Many states do not routinely collect information regarding motor vehicle crashes associated with seizures unless there is personal injury or property damage other than to a motor vehicle [13]. In one study of 50 seizure-related crashes, only half were reported to the motor vehicle division by the police, patient, family, or clinician [14]. Concern for higher rates of motor vehicle crashes in people with epilepsy is demonstrated by the following studies:

●In a 10-year Danish cohort study of 159 people with epilepsy and 559 controls, 10 people with epilepsy and 5 controls had a motor vehicle crash for which they were referred to an emergency department [15]. This represented a seven-fold higher rate of crash per 1,000 person-years in people with epilepsy compared with controls. It may be that the risk appears higher in this study because people with crashes caused by seizures (because of postictal confusion or witnessed convulsion) are more likely to be referred for medical evaluation than people with crashes unrelated to seizures. It is also important to note that in most cases, the medical record did not identify that seizure was the cause of the crash.

●Among 367 people with medically refractory epilepsy referred for surgical evaluation who completed a survey, 31 percent had driven within the previous year; more than half of these drove daily [16]. Almost 40 percent had had a seizure while driving at some point in their history, and 27 percent had had a seizure-related motor vehicle crash. However, this is a subset of people who have more frequent seizures and are therefore at higher risk of seizure-related crashes.

Characteristics of seizure-related crashes — It has been suggested that seizure-related motor vehicle crashes are less severe [7]. However, one survey of drivers with epilepsy in England found that, while the overall crash rate was similar to people without epilepsy, there was a 40 percent increase in the relative risk of serious injury and a two-fold increase in the relative risk of nondriver fatalities [8]. This study did not distinguish between seizure-related crashes and nonseizure-related crashes in the drivers with epilepsy. However, in other population-based studies, seizure-related crashes were less likely to involve another car (32 versus 78 percent) [6]. In an Australian study, 71 seizure-related motor vehicle crashes were compared with nonseizure-related crashes as controls; seizure-related crashes more frequently involved a single vehicle (57 versus 29 percent), had a single occupant (95 versus 48 percent), and involved collision with a fixed object (54 versus 17 percent) [17].

Some studies suggest that most seizures that cause a motor vehicle crash are seizures classified as focal with impaired awareness (75 percent) [18]. Other data suggest that people with primary generalized and secondary generalized convulsions may also have a higher risk of crash than population controls [15].

RISK FACTORS FOR SEIZURE-RELATED CRASHES

Seizure-free interval — A variety of factors influence an individual's risk for seizure recurrence and therefore risk of seizure-related motor vehicle crash. However, the seizure-free interval has been widely adopted by regulatory agencies as a practical measure of driving risk. The seizure-free interval is also used to gauge seizure remission and has demonstrated utility in guiding the decision to discontinue antiseizure medications. (See "Approach to the discontinuation of antiseizure medications", section on 'Estimating seizure recurrence risk'.)

There is some evidence that the seizure-free interval influences crash risk. In an epilepsy clinic-based case-control study, 50 participants with epilepsy involved in motor vehicle crashes were compared with 50 age- and sex-matched drivers with epilepsy who were not involved in crashes during the same study year [14]. The seizure-free interval was the strongest predictor of crash. Longer seizure-free intervals were associated with a reduced odds ratio (OR) of crash: 0.08 for >12 months, 0.15 for >6 months and 0.43 (no longer statistically significant) for >3 months.

By contrast, a study found no difference in the reported rates of seizure-related crashes before and after a state law reduced the required seizure-free interval from 12 to 3 months [6]. A death certificate analysis of fatal seizure-related crashes also did not find significant differences between states with shorter (three month) versus longer (6 to 12 month) requirements for freedom from seizures, but the study had limited power for this analysis [11].

Many feel that this experience reflects a trade-off between a potentially safer, longer seizure-free interval requirement, versus the increased adherence with a shorter seizure-free interval requirement. That is, while a longer seizure-free interval decreases the risk that an individual will experience a seizure-related crash, increased adherence to the shorter time requirement results in overall fewer seizure-related crashes, because fewer people with uncontrolled seizures are driving.

A 1994 consensus statement from the American Academy of Neurology (AAN), American Epilepsy Society (AES), and the Epilepsy Foundation of America (EFA) advocated a three-month seizure-free interval, with allowance for modifiers that may extend or shorten the interval (table 1) [19]. An updated consensus statement is awaited. A 2017 outcome study from Maryland, a state that implemented these consensus guideline regulation for drivers with epilepsy, supports such proposed standards [20]. (See 'Other risk factors' below and 'Mitigating factors' below.)

In comparison, a symposium of clinicians and driving regulators from the European Union advocated a one-year seizure-free interval [21], and a symposium in Canada elicited a consensus for a 6- to 12-month seizure-free requirement [22]. However, regulations in states and countries may differ substantially from consensus guidelines. One pilot study proposed use of a standardized, rigorous decision tree method to more objectively determine fitness to drive in epilepsy [23]. Compared with the existing conventional certification system in two Australian states, the decision tree model found that among people with epilepsy considered fit to drive by their physician, 6 percent did not meet the national standard to drive [23].

In general, neither guidelines nor regulations should substitute for clinical judgment. As an example, a person with epilepsy who has regularly had seizures every four or more months for many years may at times be seizure-free for three months and therefore eligible for licensure in some states; however, such individuals probably warrant a longer seizure-free interval before driving would be considered acceptably safe [3,12,14,19].

Discontinuing medication — We suggest that clinicians warn people with epilepsy about the increased risk of seizure occurrence when medications are reduced or stopped. In some cases, frequent driving by a person with epilepsy may be a reason to continue antiseizure medications despite a long period of seizure remission [24,25]. (See "Approach to the discontinuation of antiseizure medications".)

Because the risk for seizures during medication discontinuation is as high as for some people with newly diagnosed seizures, some clinicians suggest that people refrain from driving until they have been seizure-free off antiseizure medications for the same interval of time recommended for the initial seizure-free interval in their state or country. Some states and countries require people with epilepsy to refrain from driving for a period of time after antiseizure medications are stopped [13,26], while others do not have specific regulations in this regard.

The MRC Antiepileptic Drug Withdrawal study prospectively followed 406 participants with epilepsy who were in remission for at least two years and had been randomly assigned to slow antiseizure medication withdrawal [26]. The recurrence risk for these individuals was 30 percent over twelve months following antiseizure medication withdrawal. Among those who were seizure-free for three months following antiseizure medication discontinuation, the 12-month seizure recurrence risk was 15 percent, and for those who were seizure-free for six months, the risk was 9 percent.

There is limited information regarding seizure or crash risk during and after antiseizure medication withdrawal or change in medication. In a case-control study of seizure-related crashes, switching or tapering antiseizure medications significantly reduced, rather than increased, the odds of a crash [14]. One possible explanation for this observation is that people voluntarily modified or reduced their driving during that time.

Other risk factors — Aside from seizure-free interval and antiseizure medication discontinuation, other potential risk factors for motor vehicle crash in persons with epilepsy include [19,27]:

●Nonadherence with medication or medical visits

●Alcohol or substance misuse

●Structural brain disease

●Uncorrectable brain functional or metabolic disorder

●Frequent seizure recurrences after seizure-free intervals

●Prior crashes caused by seizures

The presence of any of these risk factors should lead the clinician to consider extending the seizure-free interval requirement for driving, but no specific recommendations for the length of the extension in any of these situations have been made [19]. People with epilepsy may also be advised of an increased driving risk if they miss an antiseizure medication dose or in the setting of other provocative conditions such as sleep deprivation.

Most of these were identified because they are risk factors for recurrent seizures rather than for a motor vehicle crash per se. While one case-control study did not find that antiseizure medication nonadherence was a risk factor for crash, several crashes did occur in temporal approximation with missed antiseizure medication doses [14]. Clinicians should warn people with epilepsy about possible driving risks after missing antiseizure medication doses.

NONSEIZURE-RELATED CRASH RISK — 

Some studies suggest that most motor vehicle crashes in persons with epilepsy are not seizure-related [9]. This is difficult to ascertain.

●Adverse effects of antiseizure medications – However, underlying brain disease and the cognitive effects of antiseizure medications may contribute to accidents in persons with epilepsy [28]. The sedating effects of antiseizure medications are of greatest concern when a drug is first started or the dose is increased.

●Other neurologic impairments – Clinicians should also consider neurologic deficits other than seizures (eg, cognition, visual field defects) when giving advice or making recommendations for driving. People who undergo epilepsy surgery for mesial temporal lobe epilepsy often have a postoperative visual field cut, but this is typically not of sufficient degree to require driving restriction. Decisions regarding the legality to drive are based on prescribed visual criteria, which differ by state and region. The most common acceptable requirement is 102 degrees of horizontal peripheral vision. (See "Homonymous hemianopia", section on 'Driving' and "Approach to the evaluation of older drivers", section on 'Cognitive function'.)

●Nonepileptic events mimicking seizures – Clinicians may see and care for people with nonepileptic events that mimic epileptic seizures. Unlike epileptic seizures, these events are not a consequence of abnormal electrical discharges of the brain but are instead due to other physiologic disorders, such as syncope or migraine, or are psychogenic or functional in nature (see "Functional seizures: Etiology, clinical features, and diagnosis").

When there is a physiologic cause for the events, management should focus on the underlying condition, and rules regarding driving are governed accordingly. When events are not due to physiologic causes, they may be termed functional. Various other terms are used, with the most popular currently being psychogenic nonepileptic seizures. Recommendations about driving for people with psychogenic nonepileptic seizures should be individualized (see "Functional seizures: Management and prognosis", section on 'Driving safety'). In addition, there is an International League Against Epilepsy guideline regarding driving for people with psychogenic nonepileptic seizures [29].

MITIGATING FACTORS — 

Several specific factors may be considered to modify the duration of the required seizure-free interval for driving with epilepsy [19]. These favorable modifiers may shorten or even negate this interval [12]:

●Seizures during medically directed changes in medication

●Focal seizures (only) that do not interfere with consciousness or motor function (see 'Specific types of seizures' below)

●Seizures with consistent and prolonged auras

●Acute symptomatic seizures related to acute toxic or metabolic states or illnesses that are not likely to recur or cause epilepsy (see 'Acute symptomatic (provoked) seizure' below)

●An established pattern of pure nocturnal seizures

●Seizures occurring with clear provocation (sleep deprivation) if that provocation can be avoided

Some licensing bureaus include mention of such mitigating factors, but most do not [13,21]. (See 'Legal requirements' below.)

First single unprovoked seizure — Some countries, including Canada, shorten the recommended seizure-free interval for single unprovoked seizures (ie, a seizure of idiopathic or unknown cause or remotely related to a prior brain injury such as a stroke or trauma [a so-called remote symptomatic seizure]) [30]. (See "Evaluation and management of the first seizure in adults", section on 'Unprovoked seizure'.)

In the United Kingdom, people who experience a single unprovoked seizure are usually allowed to regain ordinary driving privileges after a shorter seizure-free interval (6 months) than people with established epilepsy or recurrent seizures (12 months). The United Kingdom guidelines aim to allow driving for people with a first unprovoked seizure who have a <20 percent risk of experiencing a recurrent seizure in the next year, and use seizure freedom after a single seizure as a guideline [31,32].

However, certain clinical factors have been reported to increase the risk of seizure recurrence after a single unprovoked seizure, including having a known brain lesion as the cause of the seizure (a remote symptomatic seizure), an epileptic abnormality on electroencephalography (EEG), a significant abnormality on brain imaging, or a nocturnal seizure [33]. Such factors and others must therefore be considered in determining risk of seizure recurrence and reinstatement of the driving privilege for individuals after single unprovoked seizure. (See "Initial treatment of epilepsy in adults", section on 'First-time unprovoked seizure'.)

A prospective study that included nearly 1400 adults with a first-ever seizure found that a non-driving period of eight months was required for the monthly risk of seizure recurrence to fall to 2.5 percent; this time period varied by type of seizure and other factors [34]. A monthly seizure risk of 2.5 percent translates into an accident risk ratio of approximately 2.6, which is in the range of what has been considered acceptable by some advisory panels (although this is not a uniformly accepted or agreed upon standard) [21].

Acute symptomatic (provoked) seizure — A seizure that occurs due to a temporary illness or related to an isolated event that is unlikely to recur (acute symptomatic seizure) may not require any driving restriction. State regulatory authorities have the ultimate legal responsibility for determining when an individual may drive after a seizure, but physicians provide input and may offer guidance to patients about risks. It is advisable to warn patients to avoid driving until a full evaluation is completed, and it is determined by the regulatory authority that the risk of seizure recurrence is sufficiently low that the person may resume driving safely.

A distinction should be made for acute symptomatic seizures that occur as a result of acute stroke or head trauma; these may not herald epilepsy, but these individuals are at higher risk of recurrent seizures. Acute symptomatic seizures are discussed in greater detail separately:

●(See "Posttraumatic seizures and epilepsy".)

●(See "Overview of the management of epilepsy in adults", section on 'Poststroke seizures'.)

●(See "Evaluation and management of the first seizure in adults", section on 'Acute symptomatic (provoked) seizure'.)

Specific types of seizures — It may be reasonable to modify or negate the seizure-free interval requirement for selected patients who only have focal seizures with retained awareness, seizures with reliable, prolonged auras, or pure nocturnal seizures.

However, the pattern of these seizures must be well established. Some recommend a stable pattern for at least one year [30].

●Focal seizures with retained awareness – While focal seizures that do not affect consciousness or awareness are considered low risk for crash, it has been reported that motor activity without loss of consciousness during focal seizures has been responsible for some crashes [18]. Driving risk should be individually assessed for these patients based on their symptoms.

●Reliable auras – The presence of reliable epileptic auras (ie, a consistent and prolonged aura occurring before all or nearly all seizures experienced by an individual with epilepsy) has been associated with a lower risk of motor vehicle accidents due to seizures in some but not all reports. Reliable auras are typically seen in people with focal seizures. In one case-control study, drivers with epilepsy who had consistent, reliable auras were less likely to have a motor vehicle crash than those without consistent auras (odds ratio = 0.08) [14]. People with reliable auras who crashed included those with brief auras, those blocked in traffic who were unable to pull over to the side of the road, and those who had frequent auras that were not always followed by seizure. However, a later case-control study found that reliable auras were not associated with lower crash risks [35]. Patients should be advised of the potential risk of seizure auras and cautioned to pull off the road and stop driving if they experience a seizure aura.

●Nocturnal seizures and sleep-only attacks – As an example, However, sleep-only attacks, or what are termed "nocturnal seizures," are not without risk. In a systematic review of reports of people with pure sleep-related epilepsy, the annual risk of an awake seizure was estimated to be as high as 5.7 percent [36]. Many of the awake seizures occurred during medication withdrawal. People with frontal lobe epilepsy were excluded from the largest of the included papers in this review; it is possible that they have a different risk of daytime seizures. (See "Sleep-related epilepsy syndromes".)

in the United Kingdom, driving is allowed for patients with nocturnal seizures if the pattern includes sleep-only attacks for three years in a patient who has had at least two seizures in the past 10 years [21].

●Subclinical epileptiform EEG discharges – Concerns have been raised about persons with epilepsy who have very brief epileptic events that are unnoticed in daily life but may be detected on EEG and affect awareness, such as subclinical generalized spike-wave discharges [37]. Studies have found that these may correlate with impairment on attention tasks while driving in some patients [38]. However, people show strikingly different responses between the level of performance and spontaneous EEG discharges. Increased vigilance in driving may actually suppress epileptic discharges in some individuals [38]. We are not aware of any regulatory agency or any published guidelines suggesting the use of EEG abnormalities to restrict driving.

LEGAL REQUIREMENTS

Regional regulations — It is not surprising, given the limited available evidence, that regulating authorities have developed quite different laws regarding driving and epilepsy [39]. In the United States, these are state-specific [13]. Most but not all specify that a seizure-free interval is required for people with epilepsy or seizures to meet prior to licensure and driving. Some licensing bureaus mention some of the mitigating factors discussed above, but most do not.

Of note, a motor vehicle crash occurring as a result of a first-time seizure is not preventable by driving regulations for epilepsy [40]. Some series estimate these to make up 9 to 18 percent of seizure-related crashes [14,40].

State-specific rules — In the United States, state regulations vary widely and may change over time; therefore, direct consultation with the department of motor vehicles is recommended to provide the most current information regarding state-specific regulations. In the United States, the Epilepsy Foundation maintains an online State Driving Laws Database of driver's license eligibility by state.

International standards — Countries vary widely in their rules for the regulation of drivers with epilepsy or seizures [12]. For example, the European Commission of the European Union recommends a one-year period of seizure freedom for drivers of private motor cars with epilepsy, and a six-month seizure-free period for drivers with a first or single unprovoked seizure [41]. Information regarding driving restrictions in many European countries can be accessed on the Driving Regulations Task Force page of the International Bureau for Epilepsy website.

Clinician responsibilities — Clinicians have an important role in evaluating the ability to drive in people with seizures or epilepsy. Clinicians neither grant nor suspend driving privileges; this is the sole legal prerogative of the state. Nonetheless, physicians should counsel patients regarding the risks associated with driving and epilepsy and the applicable driving laws in their state or country [42].

●Mandatory reporting requirements – Clinicians are required to report patients with seizures to driving authorities in some states and countries but not others [27]. Monetary fines are the most common penalty for failure to report [43]. Physicians not reporting when required are potentially open to other legal actions.

Most consensus statements oppose mandatory clinician reporting [27]. Mandatory reporting decreases the number of active drivers licenses in persons with epilepsy, but it is not proven that this reduces motor vehicle crash risk [44-46]. The percentages of people driving with uncontrolled seizures are similar in those Canadian provinces with and without mandatory reporting [45]. Mandatory reporting has many other negative consequences, including underreporting of seizures by people with epilepsy to their clinicians [3,44,47-49].

In most states, clinicians are asked to supply medical reports for patients who have notified their motor vehicle bureau about their seizures. In some, treating clinicians actually determine specific driving restrictions for their patients with epilepsy or seizures [3,13,20]. The clinician's role is to inform the patient of risks and laws regarding driving and epilepsy. Some state regulatory authorities may request medical information and may also ask the physician whether the patient should drive. That recommendation should be reasonable and consistent with the prevailing standard of care and published guidelines. In general, clinician liability for certifying that a patient may be licensed to drive is minimal under those conditions [12,13,20]. It is advised that the clinician document discussions about driving in the patient's medical record [3,12,50].

In some instances, even in states without mandatory reporting, it may be appropriate for a clinician to report a person driving with epilepsy to state authorities. As an example, a person with uncontrolled seizures that causes a crash because of a seizure is at high risk for subsequent crashes. If such an individual refuses to self-report, we strongly consider and often report the individual ourselves. We inform the person and document in the chart that we advised the individual to stop driving immediately. A letter sent to the state is brief and factual, stating simply that this is my patient, the person has seizures, and the person was advised by me not to drive. A copy of that same letter is sent to the patient.

It is important to note that some states offer legal protection for such reporting while others do not; clinicians should therefore be aware of their professional responsibilities and the legal requirements of the states and countries in which they practice. When determining whether to report a patient's medical condition that may impair driving, physicians may have to weigh conflicting guidelines: a professional obligation to report and a legal requirement to maintain confidentiality, even in the face of danger to the public [51].

●Alternative transportation options – Clinicians should direct appropriate patients to alternative transportation options such as public transportation and transportation resources for people with disabilities such as seizure and epilepsy. In the United States, local state affiliates of the national Epilepsy Foundation are potential resources for this type of information. They can be identified and reached through the national Epilepsy Foundation website [52].

Alternative living situations may also be considered or discussed with people with epilepsy and their families and/or caregivers. For example, for some individuals, moving to a more urban area with better public transportation options may warrant consideration. Self-driving cars or autonomous vehicles have the potential to be practical solutions in the future for transportation issues for many people with disabilities, including epilepsy [52].

Patient responsibilities — All states in the United States require drivers with epilepsy or seizures to report their condition [13]. While specific rules and procedures vary among states, potential drivers are usually questioned at the time of licensure application about medical conditions that might affect driving; epilepsy or seizures are usually specifically mentioned [12,20].

Some confusion also exists as to reporting requirements for people with legal driving licenses who experience recurrent or new seizures [3]. Most state motor vehicle administrations may assume that people are required to report seizures immediately, but do not always specifically indicate when a seizure must be reported, or specify when a person is required to stop driving after a seizure. In fact, the wording of some state regulations implies that epilepsy or seizures need only be reported at the time of license renewal, but this is probably not their intent.

This policy of voluntary reporting is not entirely effective. Many drivers with epilepsy fail to report their condition on license applications [3,14]. Among 638 people counseled by their clinician to notify the licensing bureau about a new diagnosis of seizures, only 27 percent provided this information to the licensing bureau [53].

People with epilepsy or seizures mays fail to report for a variety of reasons. Some simply wish or need to continue driving. Others fear the stigma of a license suspension. Others may be unaware of their responsibility. Surveys indicate that 14 to 44 percent of people with epilepsy are aware of their state's driving regulations regarding epilepsy [49,54]. In one British study of adults with a first seizure, only 21 percent received the correct advice about driving [55]. Among individuals who continue to drive despite opposing advice from their physician, employment-related factors are the most common reasons for nonadherence [49,56].

Failure to report has significant consequences for people with epilepsy if involved in a motor vehicle crash. Insurance companies may not assume liability if a person has failed to report. People with epilepsy may also be financially and even criminally responsible for damage and injury resulting from seizure-related crash [43].

Commercial drivers — Commercial driving restrictions for people with seizures or epilepsy are stricter than those pertaining to private motor vehicle use. In the United States, regulations regarding commercial vehicles involved in intrastate commerce vary among individual states. They often parallel restrictions for noncommercial driving but are usually stricter and require a longer seizure-free interval. Individually, states are increasingly implementing standards for intrastate commercial driving that are similar to the federal government standards for interstate commercial driving. Many states have specific regulations concerning school bus or other bus drivers [3,57].

Federal regulations before April 2014 in the United States specifically prohibited interstate commercial driving by any person with epilepsy or taking antiseizure medications [3,19]. These standards remain in the Federal Motor Carrier Safety Administration Medical Examiner Handbook [58] but have effectively been modified to allow exceptions or waiver for individuals who apply, based on the slightly less strict recommendations for restrictions of a 2007 expert panel [59]. However, the process of obtaining these approvals is rather complicated and requires an individual specifically apply for exception from the prior restrictions [17,59,60]. Examples of the recommendations that govern these exemptions include the following [59]:

●An individual must have been seizure-free for a minimum of eight years on or off antiseizure medications, and:

•if all anti-seizure medications have been stopped, the individual must have been seizure-free for minimum of eight years from the time of medication cessation, or

•if still using anti-seizure medication, the individual must have been on a stable medication regimen for a minimum of two years.

●An individual with a history of epilepsy who has been granted conditional certification to drive a commercial motor vehicle must be recertified on an annual basis.

People who experience a seizure caused by a known medical condition, such as an acute infection or metabolic disturbance (acute symptomatic seizure), are deferred from licensure as commercial drivers until they are fully recovered from that condition and have no significant residual complications. Several other countries have different rules and regulations. As an example, in the United Kingdom, the law prohibits any person who has suffered an epileptic attack since the age of five years from driving a heavy or public service vehicle [57].

SOCIETY GUIDELINE LINKS — 

Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Seizures and epilepsy in adults".)

INFORMATION FOR PATIENTS — 

UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topics (see "Patient education: Epilepsy in adults (The Basics)" and "Patient education: Time to stop driving? (The Basics)")

SUMMARY AND RECOMMENDATIONS

●Driving regulations – It is generally accepted that the risk of a motor vehicle crash is increased for people with epilepsy. Because of this concern, driving with epilepsy or after a seizure is regulated. Because of limited data, driving restrictions are often based on rather arbitrary standards. (See 'Introduction and overview' above and 'Magnitude of risk' above.)

●Risk factors

•Seizure-free interval – The seizure-free interval is the most practical and widely used measure of a person's driving risk. Longer seizure-free intervals (>6 to 12 months) are associated with a reduced risk of a seizure-related motor vehicle crash. However, shortening the required seizure-free interval to three months by some states has not been associated with increased crashes. States and countries have different seizure-free interval requirements for licensure. (See 'Seizure-free interval' above.)

•Other risk factors – High seizure frequency, medical nonadherence, a history of motor vehicle crashes, and other factors may increase the risk of a seizure-related crash. These should be considered to extend the seizure-free interval requirement for driving recommendations. (See 'Other risk factors' above.)

●Mitigating factors – Factors that may reduce the risk of a seizure-related crash include an established pattern of purely nocturnal seizures, consistent and reliable seizure auras, clear seizure provocation, and acute symptomatic seizures caused by a condition that is not associated with epilepsy. (See 'Mitigating factors' above.)

●Other considerations – Clinicians should also consider other neurologic contraindications for driving that may coexist with seizures in their patients with epilepsy, including impaired cognition and visual field defects. (See 'Nonseizure-related crash risk' above.)

●Legal regulations – Clinicians should be knowledgeable regarding the laws and reporting responsibilities in the state in which they practice. In the United States, the Epilepsy Foundation maintains a State Driving Laws Database of driver's license eligibility by state. Information regarding driving restrictions in many European countries can be accessed on the Driving Regulations Task Force page of the International Bureau for Epilepsy website. (See 'Regional regulations' above.)

Clinicians should discuss driving with patients and record this discussion in the medical record. This discussion should include the risk of driving as well as the state regulations regarding driving restrictions and reporting requirements in patients with epilepsy. (See 'Clinician responsibilities' above.)

People with epilepsy or seizures should be encouraged to comply with state regulations. Even when reporting is not mandated, clinicians may consider reporting very high-risk patients who continue to drive against medical advice and pose a substantial, imminent risk to public safety. (See 'Patient responsibilities' above.)

●Alternative resources – Clinicians should direct appropriate patients to alternative transportation options such as public transportation and state and local resources for transportation for people with disabilities such as seizure and epilepsy. (See 'Clinician responsibilities' above.)