Driving restrictions for people with seizures and epilepsy

INTRODUCTION — 

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, significantly diminishing 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.

This topic will 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

Risk of crash with seizures — The contribution of seizures and epilepsy to the burden of motor vehicle crashes is not entirely certain. Studies indicate that most motor vehicle crashes in persons with epilepsy are not seizure-related but are related to driver error [4], as is the case for drivers without epilepsy.

●Risk compared with the general population – While data vary, the risk of a motor vehicle crash is probably increased for people with epilepsy [5-7]. A 2015 systematic review identified several observational studies of crash rates in drivers with epilepsy compared with other drivers [8]. In three included studies using objective measures (hospital records, medical and insurance databases, and police reports) to assess crashes, patients with epilepsy had an increased risk for crashes compared with drivers without epilepsy, with a relative risk ranging from 1.62 to 7.01. By contrast, in two included studies using self-reported motor vehicle crashes, the risk of a crash was similar in drivers with and without epilepsy.

Population statistics and survey data vary, but estimates typically show that less than one percent of all crashes are attributable to seizures [9,10].

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). In comparison, the rate of fatal crashes caused by alcohol use was eight times greater than for crashes caused by seizures.

●Risk compared with other medical conditions – 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; the risk 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 [5,6,12].

●Impact of driving restrictions on the crash rate – The data cited above do not support a conclusion that driving restrictions for persons with epilepsy are always discriminatory. The data on epilepsy and motor vehicle crash risk are collected under current driving restrictions. While adherence is imperfect, driving regulations almost certainly limit driving by persons with epilepsy and thereby lower crash rates compared with what they might be if all persons with epilepsy drove unrestricted.

●Is the risk underestimated? – Available statistics may 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 their 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 raised by other 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 sevenfold higher rate of crash per 1,000 person-years in people with epilepsy compared with controls. It may be that the risk appeared higher in this study because people with crashes caused by seizures (because of postictal confusion or witnessed convulsion) were more likely to be referred for medical evaluation than people with crashes unrelated to seizures. In most cases, the medical record did not identify that seizure was the cause of the crash.

In another report of 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 — Several studies have reported that crashes involving drivers with epilepsy are associated with an increased risk of death, injury, or property damage compared with control drivers without epilepsy [4,15,17,18].

One survey of drivers with epilepsy in England found that, while the overall crash rate was similar to that of people without epilepsy, there was a 40 percent increase in the relative risk of serious injury and a twofold increase in the relative risk of nondriver fatalities [17]. This study did not distinguish between seizure-related and nonseizure-related crashes among drivers with epilepsy. In other population-based studies, seizure-related crashes were less likely to involve another car (32 versus 78 percent) [9].

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) [18].

Another Australian case-control study identified 57 patients with a first seizure while driving [19]. A first seizure while driving was associated with loss of vehicle control in 80 percent, crash in 64 percent, and injury in 41 percent; the most common seizure type was tonic-clonic. Compared with a first seizure at other times, a first seizure while driving was associated with an increased incidence of a second seizure.

RESTRICTIONS REQUIRED AFTER A SEIZURE

Immediate steps — In nearly all cases and jurisdictions with regulations, a new or recurrent seizure requires that the patient:

●Stop driving immediately.

●Refrain from driving until seizure-free for a specified period (typically three months to one year, depending upon the state or country); the seizure-free duration and driving fitness may require certification by a licensed physician. (See 'Clinician responsibilities' below and 'Duration of driving restriction' below.)

Clinicians should counsel patients regarding the risks associated with driving and epilepsy and the applicable driving laws in their state or country. In some jurisdictions, the patient or clinician is required to report seizure occurrence to driving authorities. (See 'Clinician responsibilities' below.)

Circumstances that may modify these restrictions (in some jurisdictions) are discussed below. (See 'Modifying factors' below.)

Legal regulations — Given the inconsistent evidence (see 'Magnitude of risk' above), it is not surprising that regulating authorities have developed quite different laws regarding driving and epilepsy [20].

Of note, a motor vehicle crash occurring as a result of a first-time seizure is not preventable by driving regulations for epilepsy [21]. Some series estimate these to make up 9 to 18 percent of seizure-related crashes [14,21].

Noncommercial drivers

●United States – In the United States, laws regarding driving and epilepsy are state-specific [13]. For noncommercial drivers, most states specify that a seizure-free interval is required before allowing licensure and driving. State regulations vary widely and may change over time; some licensing bureaus mention one or more of the mitigating factors (eg, acute symptomatic seizures) discussed below (see 'Modifying factors' below), but most do not.

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 – Countries vary widely in their rules for regulating 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 [22]. 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.

Driving laws in Canada are summarized on the Driving web page of the Canadian Epilepsy Alliance.

However, many countries do not have regulations governing driving eligibility for people with seizures or epilepsy [20].

Commercial drivers — Commercial driving restrictions for people with seizures or epilepsy are stricter than those pertaining to private motor vehicle use.

●International – Rules and regulations vary by country [23]. Most European countries require a seizure-free interval of five years or more without using antiseizure medications for people with epilepsy [22].

●United States – 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 intrastate commercial driving standards similar to the federal government standards for interstate commercial driving. Many states have specific regulations concerning school bus or other bus drivers [3,24].

In the United States, federal regulations specifically prohibit interstate commercial driving by any person with epilepsy taking antiseizure medications, as stipulated in the Federal Motor Carrier Safety Administration Medical Examiner Handbook [25]. To be qualified to drive a commercial motor vehicle, an individual with a diagnosis of epilepsy or seizure disorder must have been seizure-free for a minimum of 10 years off antiseizure medications.

While these standards remain, they have effectively been modified to allow exemptions for individuals who apply, based on the slightly less strict recommendations for restrictions from a 2007 expert panel [26]. However, the process is rather complicated and requires an individual to apply for an exemption from the prior restrictions [18,26,27]. Examples of the recommendations that govern these exemptions include the following [26]:

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

-If all antiseizure medications have been stopped, the individual must have been seizure-free for a minimum of eight years from the time of medication cessation, or

-If still using antiseizure medication, the individual must have been on a stable medication regimen for at least 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.

Modifying factors — Several factors may be considered to modify the duration of the required seizure-free interval for driving with epilepsy [28,29]. These favorable modifiers may shorten or even negate this interval [12]:

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

●Certain types of seizures (see 'Seizure types and driving risk' below):

•Focal seizures (only) that do not interfere with consciousness or motor function

•An established pattern of pure nocturnal seizures

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

●Seizures during medically directed changes in medication, such as during hospitalization in an epilepsy monitoring unit for seizure evaluation

Some licensing bureaus mention such mitigating factors, but many do not [13,30].

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 [12,31].

The clinician should document discussions about driving in the patient's medical record [3,12,32].

●Providing medical reports – In many states and countries, clinicians are asked to supply medical reports for patients who have notified their licensing agency about their seizures. In some cases, treating clinicians determine specific driving restrictions for their patients with epilepsy or seizures [3,13,33]. The clinician's role is to inform the patient of risks and laws about driving and epilepsy.

Some state regulatory authorities may request medical information and 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 [12,13,33].

●Mandatory reporting requirements – Clinicians are required to report patients with seizures to the licensing agency in some states and countries but not others [34]. Monetary fines are the most common penalty for failure to report [35]. Physicians who do not report when required are potentially open to other legal actions.

Most consensus statements oppose mandatory clinician reporting [29,34]. Mandatory reporting decreases the number of active driver's licenses in persons with epilepsy, but it is not proven that this reduces motor vehicle crash risk [36-38]. The percentages of people driving with uncontrolled seizures are similar in those Canadian provinces with and without mandatory reporting [37]. Mandatory reporting has many other negative consequences, including underreporting of seizures by people with epilepsy to their clinicians [3,36,39-41].

●Other circumstances that may prompt reporting – In some instances, even in states and countries 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 who has 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 I advised the person not to drive. A copy of that same letter is sent to the patient.

Some jurisdictions 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 where 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 [42].

●Alternative transportation options – Clinicians should direct appropriate patients to alternative transportation options, such as public transportation and transportation resources for people with disabilities, including seizures and epilepsy [29]. 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 [43].

Alternative living situations may also be considered or discussed with people with epilepsy and their families and/or caregivers. For example, moving to a more urban area with better public transportation options may warrant consideration for some individuals. 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 those with epilepsy [43].

Patient responsibilities and failure to report — Many countries and 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 [12,33].

Voluntary reporting by patients 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 [44].

People with epilepsy or seizures may 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 [41,45]. In one British study of adults with a first seizure, only 21 percent received the correct advice about driving [46]. Among individuals who continue to drive despite opposing advice from their physician, employment-related factors are the most common reasons for nonadherence [41,47].

Failure to report has significant consequences for people with epilepsy if they are 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 a seizure-related crash [35].

FAVORABLE AND UNFAVORABLE RISK FACTORS FOR SEIZURE-RELATED CRASHES — 

Various factors influence an individual's risk for seizure recurrence and a seizure-related motor vehicle crash.

Duration of driving restriction — Regulatory agencies have widely adopted the seizure-free interval as a practical measure of driving risk; the interval is generally three months to one year, depending upon the state or country, although some states do not specify a seizure-free interval. Nevertheless, patients with epilepsy and active seizures that impair awareness or motor control should not drive.

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'.)

●Data – 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 [9]. 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 fewer seizure-related crashes overall, because fewer people with uncontrolled seizures are driving.

●Consensus guidelines – Consensus guidelines from the American Academy of Neurology, American Epilepsy Society, and Epilepsy Foundation of America recommend a minimum seizure-free interval of three months before driving [29], with allowance for individual factors that may extend or shorten the interval (table 1). (See 'Other risk factors' below.)

In comparison, a symposium of clinicians and driving regulators from the European Union advocated a one-year seizure-free interval [30], and a symposium in Canada elicited a consensus for a 6- to 12-month seizure-free requirement [48]. However, regulations in states and countries may differ substantially from consensus guidelines [49]. One pilot study proposed a standardized, rigorous decision tree method to more objectively determine fitness to drive in epilepsy [50]. 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 driving standard [50].

●Individualized decisions – Generally, 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 [3,12,14,28].

Unprovoked and provoked seizures

●First single unprovoked seizure – Unprovoked seizure refers to a seizure of unknown etiology as well as one that occurs related to a preexisting brain lesion or progressive nervous system disorder. Unprovoked seizures that are determined to be due to an underlying brain lesion or disorder are also referred to as remote symptomatic seizures. (See "Initial treatment of epilepsy in adults", section on 'First-time unprovoked seizure'.)

Certain clinical factors have been reported to increase the risk of seizure recurrence (ie, epilepsy) after a single unprovoked seizure, including having a remote symptomatic cause (brain lesion or prior central nervous system [CNS] infection), an epileptic abnormality on electroencephalography (EEG), a significant abnormality on brain imaging, a nocturnal seizure, or when it is the first presentation of an epilepsy syndrome [51]. (See "Initial treatment of epilepsy in adults", section on 'Second unprovoked seizure'.)

For patients with a first unprovoked seizure who have no history of a remote brain insult and have a normal (or nonfocal) examination beyond the postictal period, factors associated with a lower risk of seizure recurrence include an interictal EEG without epileptiform activity and normal (or nonspecific) neuroimaging.

Such factors and others must therefore be considered in determining the risk of seizure recurrence and reinstatement of the driving privilege for individuals after a 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 nondriving period of eight months was required for the monthly risk of seizure recurrence to fall to 2.5 percent; this period varied by type of seizure and other factors [52]. 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) [30].

Some countries, including Canada, shorten the recommended seizure-free interval for single unprovoked seizures to three months, compared with six months for people with epilepsy [53].

Similarly, people who experience a single unprovoked seizure in the United Kingdom are usually allowed to regain ordinary driving privileges after a shorter seizure-free interval (six 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 [54,55].

●Acute symptomatic (provoked) seizure – An acute symptomatic or provoked seizure is one due to a temporary illness or an isolated event unlikely to recur. This type of seizure has a low risk of future epilepsy and may not require any driving restriction [29]. Individuals should not drive after a provoked seizure until a full seizure evaluation is completed and the risk of seizure recurrence has returned to the preseizure baseline. Regulatory authorities have the ultimate legal responsibility to determine when an individual may drive after a seizure, but physicians provide input and should offer guidance to patients about risks.

A distinction should be made for acute symptomatic seizures that occur as a result of acute stroke or head trauma; these individuals are at higher risk of recurrent seizures. Acute symptomatic seizures are discussed in greater detail separately:

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

•(See "Posttraumatic seizures and epilepsy".)

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

Seizure types and driving risk — 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 [53].

●Seizures that impair awareness or motor control – Not surprisingly, some studies suggest that focal seizures with impaired awareness are the cause of most (75 percent) seizure-related motor vehicle crashes [56]. Primary generalized and focal to bilateral tonic-clonic seizures (secondarily generalized seizures) also cause crashes [15,19].

●Focal seizures with retained awareness – While focal seizures that do not affect consciousness or awareness are considered low risk for crash, motor activity without loss of consciousness during focal seizures has been responsible for some crashes [56]. Driving risk should be individually assessed for these patients based on their symptoms. A clinical assessment from the treating clinician is needed, and recommendations and/or comments should be provided to the motor vehicle administration.

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 (OR = 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 [57].

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 – 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 [58]. 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 [30].

●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 [59]. Studies have found that these may correlate with impairment on attention tasks while driving in some patients [60]. However, people show strikingly different responses between the level of performance and spontaneous EEG discharges. Increased vigilance in driving may suppress epileptic discharges in some individuals [60]. We are unaware of any regulatory agency or published guidelines suggesting using EEG abnormalities to restrict driving.

Discontinuing medication — We suggest that clinicians warn people with epilepsy about the increased risk of seizure occurrence when medications are reduced or stopped. A 2025 consensus statement recommends limiting driving during antiseizure medication tapering and following antiseizure medication discontinuation [29]. 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 [61,62]. (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 [13,63], while others do not have specific regulations in this regard.

The Medical Research Council 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 [63]. 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; 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 a 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 — Other potential risk factors for motor vehicle crashes in persons with epilepsy include [28,29,34,64]:

●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

●Adverse effects of antiseizure medications

●Other neurologic impairments (eg, visual field cut)

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 [28]. 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.

Underlying brain disease and the cognitive effects of antiseizure medications may contribute to accidents in persons with epilepsy [64]. The sedating effects of antiseizure medications are of greatest concern when a drug is first started or the dose is increased.

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 of driving 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.

Functional seizures — When events that mimic seizures are not due to physiologic causes, they may be termed functional seizures, also known as psychogenic nonepileptic seizures. (See "Functional seizures: Etiology, clinical features, and diagnosis" and "Functional seizures: Management and prognosis".)

Limited retrospective evidence is inconsistent about whether patients with functional seizures have an increased risk of motor vehicle crashes [65-67].

Although evidence is limited, a 2025 consensus statement recommended that individuals with functional seizures (characterized by movements or altered responsiveness likely to disrupt driving) should be restricted from driving until free of functional seizures for at least three months or the seizure-free interval for epileptic seizures required by local driving regulations [29]. The consensus statement recommended that the criteria for when driving may resume should be similar to the criteria for drivers with epileptic seizures and modified by individualized review [29].

Based mainly upon expert opinion, an International League Against Epilepsy (ILAE) guideline proposed the following approach regarding driving for people with functional seizures [68]:

●Factors that suggest the need for driving restrictions, as endorsed by more than one-half of the experts surveyed by the ILAE [68]:

•Loss of awareness/responsiveness with functional seizures

•History of injuries related to functional seizures

•No auras, warnings, or otherwise predictable seizures

•Patients who want to be commercial drivers

•On medication that significantly impairs driving ability

•Active suicidal intent

●Factors that suggest driving restrictions are not needed [68]:

•Functional seizures that occur only at times when the patient could not be driving (eg, in bed at night)

•Functional seizures that are always preceded by a prodrome that is long enough to allow the patient to remove the vehicle from traffic and make themselves safe

Syncope — When there is a physiologic cause for the events (eg, cardiogenic syncope, reflex syncope, orthostatic hypotension), management should focus on the underlying condition, and rules regarding driving should be governed accordingly. (See "Syncope in adults: Management and prognosis", section on 'Driving restrictions'.)

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 in most countries. (See 'Introduction' above and 'Magnitude of risk' above.)

●Restrictions after a seizure – In most cases and jurisdictions with regulations, a new or recurrent seizure requires that the patient:  

•Stop driving immediately.

•Refrain from driving until seizure-free for a specified period (typically three months to one year depending upon the state or country). (See 'Restrictions required after a seizure' above and 'Duration of driving restriction' above.)

•The patient (or clinician in some jurisdictions) should inform the licensing authority (eg, Department of Motor Vehicles, driving agency) about having a seizure; the patient should resume driving only after approval by the licensing authority.

●Legal regulations – In the United States, the Epilepsy Foundation maintains an online 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. (See 'Legal regulations' above.)

●Clinician requirements – Clinicians should counsel patients regarding the risks associated with driving and epilepsy and the applicable driving laws in their state or country; they should record this discussion in the medical record. In many states and countries, clinicians are asked to supply medical reports for patients who have notified their licensing agency about their seizures.

Clinicians are required to report patients with seizures to the licensing agency in some states and countries but not others. 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 'Clinician responsibilities' above.)

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.)

●Patient responsibilities – Many countries and all states in the United States require drivers with epilepsy or seizures to report their condition. However, many drivers fail to self-report. Failure to report has significant consequences for people with epilepsy if involved in a motor vehicle crash. (See 'Patient responsibilities and failure to report' above.)

●Favorable and unfavorable risk factors – Various factors influence an individual's risk for seizure recurrence and therefore risk of seizure-related motor vehicle crash. (See 'Favorable and unfavorable risk factors for seizure-related crashes' above.)

•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 'Duration of driving restriction' above.)

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

•Unfavorable factors – High seizure frequency, medical nonadherence, a history of motor vehicle crashes, and medication discontinuation may increase the risk of a seizure-related crash. The risk of seizure recurrence (ie, epilepsy) is also increased after a single unprovoked seizure with a remote symptomatic cause (brain lesion or prior central nervous system [CNS] infection), an epileptic abnormality on electroencephalography (EEG), a significant abnormality on brain imaging, a nocturnal seizure, or when it is the first presentation of an epilepsy syndrome. These factors suggest the need for a longer seizure-free interval requirement before resuming driving. Clinicians should also consider other neurologic contraindications for driving that may coexist with seizures in patients with epilepsy, including impaired cognition and visual field defects. (See 'Other risk factors' above.)