From Seizure to Sideline: Navigating Epilepsy in Athletes

Picture this: You're a sports neurologist, and you've just been consulted to evaluate an athlete who has presented after experiencing a seizure. The acute management is complete, workup has been performed, and treatment has been initiated. Now comes the difficult question: Do you clear the athlete to return to sport?

Historically, participation in sports by individuals with seizures or epilepsy has been limited -- largely due to fear of potential harm to the athlete or others. However, physical activity and sport offer substantial benefits for individuals with epilepsy -- not only in terms of general physical and mental well-being, but also in management. In fact, regular exercise may reduce seizure frequency and improve quality of life. If participation can be done safely, it should be encouraged.

That said, there are currently no evidence-based regulations for return-to-play after a seizure or for athletes with epilepsy. Instead, clinicians rely on expert consensus guidelines, such as those from the International League Against Epilepsy (discussed further below), and must take an individualized, risk-benefit approach to each case. This nuanced decision-making includes a careful analysis of both seizure- and sport-related factors, such as:

Seizure/Epilepsy Factors

• Focal vs. generalized onset

• Motor vs. nonmotor features

• Retained vs. impaired awareness

• Presence or absence of warning signs

• Seizure timing (daytime vs. nocturnal)

• Seizure frequency

• Level of control with treatment

  
  

Sport-Related Factors

• Type of sport

• Risk to the athlete during a seizure

• Potential risk to teammates or bystanders during a seizure

• Degree of medical supervision available

The Internal League Against Epilepsy—an organization whose name evokes the image of a superhero team of neurologists on a mission—has taken steps to fill the gap in formal guidelines. In 2016, their Task Force on Sports and Epilepsy published a consensus paper that offers sport categorization based on risk to both athlete and others should a seizure occur (Table 1), as well as suggestions regarding participation based on sport categorization and seizure/epilepsy-related factors (Table 2, PMID 26662920). Though these recommendations are not yet evidence-based, they provide a valuable framework for clinicians.

Seizures are among the most common neurologic conditions in the general population, including athletes. Evaluation and management of seizures in athletes generally follows the same principles as for the general population, including laboratory testing, EEG, and brain MRI. Treatment focuses on lifestyle optimization (sleep, hydration, nutrition), avoidance of known triggers, and medication adherence. While exercise doesn’t alter the pharmacokinetics of anti-seizure medications, clinicians must still carefully select medications, with consideration of the teratogenic risks in young female athletes of childbearing age as well as central nerve system side effects (e.g., sedation) that may impact sport performance.

Determining return-to-play after a seizure is a complex yet essential aspect of sports neurology. Although the diagnostic workup and treatment often mirror standard of care for the general population, decisions about athletic participation require a nuanced, individualized approach that considers both seizure-specific and sport-related risks. In the absence of formal evidence-based guidelines, consensus recommendations, such as those from the International League Against Epilepsy, offer a useful framework for guiding amateur, collegiate, professional, and elite athletes to safely return to play -- to continue to thrive both in their sport and beyond.