Dr Sanchez is Assistant Professor and Dr Krumholz is Professor Emeritus, Department of Neurology, University of Maryland School of Medicine, Baltimore, MD.
Worldwide there are more than 65 million individuals with epilepsy.1 In the US because driving an automobile is such an important aspect of our culture, driving restriction is an enormous problem for many of these individuals and their families. Indeed, surveys find individuals with epilepsy report driving as a major concern.2 Physicians and other medical providers play an important role educating and counseling people with seizures and their families regarding driving. Here, we provide some background and guidance regarding this issue.
Individuals with seizures are restricted from driving because of concerns that a seizure while driving might result in loss of control of the vehicle and a crash, potentially injuring the driver or others, and damaging property. Tragically, such crashes cause fatalities.3 Therefore every state in the US restricts some individuals with epilepsy from driving. Driving restrictions vary by state and are ultimately determined by the Department of Motor Vehicles (DMV).4 Physicians and other medical providers are involved to varying degrees throughout this process of driving regulation and restriction. They serve as advisers to patients, with a duty to inform patients regarding rules and regulations as well as consultants to state regulatory authorities.
To properly counsel patents, it is important that physicians and other medical providers are familiar with the rules governing driving for patients with seizure disorders. Our recommended approach to counseling patients with seizures and epilepsy regarding driving is illustrated in some of the following examples and discussion.
A 23-year-old woman presents to your office with new-onset seizures. She generally feels well, has no other relevant history, and her examination is normal. Brain MRI with and without contrast and EEG were performed and were normal.
Question: As the medical provider, how would you counsel this patient regarding driving after her first unprovoked seizure (a seizure not related to an acute precipitating cause)?
Answer: She should be informed that a seizure while driving could be dangerous and result in a motor vehicle crash. Since she has had a seizure, she is at risk for further seizures. Regulations exist in an effort to prevent injury, death, or property damage that might result if a seizure were to occur while driving. She should be informed to stop driving and that patients are required by law to report their seizures to the DMV in their state. In some states, physicians and other medical providers are also required to report (Table 1) that a patient has had a seizure.4 The DMV will determine when she may resume driving.
A seizure-free interval is typically necessary for the DMV to approve a person to drive after a first seizure, this too varies by state. The typically required seizure-free interval may be as short as three months to as long as one year.4 There may be positive or negative modifiers that shorten or lengthen the seizure-free interval (Table 2).5 Antiseizure medication (ASM) is not always prescribed after a first seizure; this is a variable that may be considered on a case by case basis.6
After reporting her seizures to the DMV, the patient and the medical provider are required to complete paperwork regarding the condition. A medical advisory board or similar type of state review will consider the case and make recommendations. Then a final decision regarding any driving restrictions will be made by the DMV. Decisions may be appealed by the patient.
1. England MJ, Liverman CT, Schultz AM, et al. Institute of Medicine (US) Committee on the Public Health Dimensions of the Epilepsies. Washington, DC: National Academies Press; 2012.
2. Gilliam F, Kuzniecky R, Faught E, ET AL. Patient-validated content of epilepsy-specific quality-of-life measurement. Epilepsia. 1997;38:233-236.
3. Sheth SG, Krauss G, Krumholz A, Li G. Mortality in epilepsy: Driving fatalities vs other causes of death in patients with epilepsy. Neurology. 2004;63:1002-1007.
4. Krauss GL, Ampaw L, Krumholz A. Individual state driving restrictions for people with epilepsy in the US. Neurology. 2001;57:1780-1785.
5. American Academy of Neurology, American Epilepsy Society, and Epilepsy Foundation of America. Consensus statements: Sample statutory provisions, and model regulations regarding driver licensing and epilepsy. Epilepsia. 1994;35:696-705.
6. Krumholz A, Wiebe S, Gronseth GS, et al. Evidenced-based guideline: management of an unprovoked seizure in adults. Report of the Guideline Development Subcommittee of the American Academy of Neurology and the American Epilepsy Society. Neurology. 2015:84:1705-1713.
7. Bonnett LJ, Shukralla A, Tudur-Smith C, et al. Seizure recurrence after antiepileptic drug withdrawal and the implications for driving: further results from the MRC antiepileptic drug withdrawal study and a systematic review. J Neurol Neurosurg Psychiatry. 2011;82:1328-1333.
8. Krauss GL, Krumholz A, Carter RC, et al. Risk factors for seizure-related motor vehicle crashes in patients with epilepsy. Neurology. 1999;52:1324-1329.
9. Ma BB, Bloch J, Krumholz A, et al. Regulating drivers with epilepsy in Maryland: results of the application of a United States consensus guideline. Epilepsia. 2017;58:1389-1397.
10. Punia V, Farooque P, Chen W, et al. Epileptic auras and their role in driving safety in people with epilepsy. Epilepsia. 2015;56:e182-185
11. Epilepsy Foundation. State Driving Laws Database. https://www.epilepsy.com/driving-laws. Accessed August, 29, 2018.