Epilepsy in Sport

A seizure arises from abnormal, synchronous neuronal activity. Epilepsy is the enduring predisposition to seizures, classically defined by two unprovoked seizures more than 24 hours apart, although it may be diagnosed after a single unprovoked seizure when the risk of recurrence is high or an epilepsy syndrome is identified. Seizures are broadly focal, starting in one part of the brain with awareness kept or impaired and sometimes spreading, or generalised, involving both sides from the outset and including the convulsive tonic-clonic type, brief absences and myoclonic jerks.

It helps to separate an athlete's precipitants from acute symptomatic causes. Recognised precipitants in susceptible people include missed medication, sleep deprivation and alcohol excess or withdrawal, while photosensitivity and hyperventilation apply only to particular syndromes. By contrast, hypoglycaemia, significant electrolyte disturbance, acute illness and head injury can directly cause an acute symptomatic seizure. Exercise itself rarely provokes seizures and is generally safe, and extreme endurance effort, where it contributes, usually acts indirectly through sleep loss, illness or metabolic disturbance.

A convulsive tonic-clonic seizure is usually recognisable: sudden loss of consciousness, stiffening then rhythmic jerking, sometimes tongue-biting or incontinence, followed by a post-ictal period of confusion and drowsiness. Focal seizures can be subtler, with localised movement, altered sensation or automatisms and variable awareness, and absences show as brief blank spells.

The crucial skill in sport is working out what a collapse actually is. A short period of seizure-like activity can occur at the very onset of a cardiac arrest, so once the movements stop the priority is to assess responsiveness and breathing: if the athlete is unresponsive and not breathing normally, assume cardiac arrest, call 999, start cardiopulmonary resuscitation (CPR) and attach an automated external defibrillator (AED) as soon as possible. Mistaking a cardiac arrest for a seizure costs lives. Other causes include simple faints, concussion, hypoglycaemia and heat illness. A transient post-ictal weakness may be Todd's paresis, but any new or persistent focal deficit must be assessed urgently for stroke, bleeding or structural disease.

A first suspected seizure warrants urgent specialist assessment, ideally within two weeks, and a clear eyewitness account or video is often more useful than any test. A twelve-lead electrocardiogram (ECG) should be done after a first seizure or collapse to identify a cardiac mimic such as an inherited arrhythmia syndrome. An electroencephalogram (EEG), performed within around 72 hours where indicated, helps classify the seizure but does not confirm or exclude epilepsy, and a normal recording is common in people who have it.

Magnetic resonance imaging (MRI) of the brain is used when a structural cause is suspected and is offered to most people once epilepsy is diagnosed. Blood tests check for provoking factors such as low glucose or sodium. The SEM doctor's role is timely referral and, above all, ruling out the dangerous mimics.

Pitchside seizure care is mostly about preventing harm. Move the athlete only if they are in immediate danger, time the seizure from its onset, protect the head and clear nearby hazards, and do not restrain them or put anything in the mouth.

Once the convulsive movements stop, check breathing and place them in the recovery position if breathing is normal, give nothing by mouth until fully recovered, and stay with them through the drowsy post-ictal phase. Rescue medication such as buccal midazolam is given only where it is set out in the athlete's own emergency plan and by someone trained to give it. Call 999 for a first seizure, a seizure over five minutes or repeated seizures without recovery, breathing difficulty, serious injury, a seizure in water, or failure to recover as expected.

The assessment afterwards covers basic observations, a capillary glucose and the conscious level, with a survey for injury to the head, cervical spine, shoulder and limbs, and an electrocardiogram where the collapse is unexplained. A seizure after head trauma is a red flag, not routine concussion: the athlete is removed from play, managed with cervical spine precautions where indicated, and transferred urgently for assessment and a head scan.

Ongoing care is usually neurologist-led, with anti-seizure medication for control and adherence emphasised, since missed doses around travel and competition commonly cause breakthrough seizures. Most anti-seizure medicines are permitted in sport, but every drug should be checked on Global Drug Reference Online, and acetazolamide is prohibited at all times as a diuretic and masking agent, so an athlete who genuinely needs it should use the UK Anti-Doping exemption process for their level.

The guiding principle is individualised risk assessment, not exclusion. Most sports are safe for people with epilepsy, particularly when seizures are well controlled, and the assessment weighs the seizure type and frequency, how good control is, the triggers, the time since the last seizure, whether there is any reliable warning, and what a seizure would mean in that specific sport.

Higher-risk activities are those where a momentary loss of awareness or control could be fatal or seriously harmful. Swimming and water sports carry a drowning risk and need supervision from someone who knows and can help, and climbing, heights, motor sport, road cycling, equestrian sport, shooting and archery, aviation and solo wilderness activity all warrant particular caution. Scuba diving is contraindicated in active epilepsy, and United Kingdom diving guidance generally requires at least five years without seizures and without anti-seizure medication before diving is considered, with specialist review for exceptional cases such as seizures confined to sleep.

Precautions can make many otherwise risky sports feasible, including supervision, a buddy system, avoiding solo participation, and choosing safer settings such as a pool over open water. Contact and collision sport is not automatically contraindicated, but governing-body rules must be checked, and some combat sports exclude affected athletes outright: under current England Boxing rules a person with epilepsy is not permitted to box. The decision is shared with the athlete and their neurologist, and the discussion of risk is documented.

Return is individualised, and there should be no same-session return after a seizure. The first steps are to confirm full neurological recovery and to identify and manage any injury, acute illness, hypoglycaemia, electrolyte disturbance or medication issue. A first or unexplained seizure needs urgent specialist assessment, and higher-consequence activities involving water, height, speed, traffic or weapons are deferred meanwhile.

Return to lower-risk exercise can be considered once the athlete has recovered and been assessed, with timing based on the cause, the degree of seizure control, the recurrence risk and the consequences of another event. There is no single seizure-free interval that fits all sports, and where a governing body sets a medical standard it takes precedence. The aim throughout is a safe return, not open-ended restriction.

• •Current National Institute for Health and Care Excellence guidance on the diagnosis and management of epilepsy covers first-seizure referral, investigation and treatment and underpins the approach here.
• •Epilepsy Action and the Epilepsy Society provide practical guidance on sport, exercise and safety for people with epilepsy.
• •Activity-specific medical standards, for example in diving, motor sport and aviation, and governing-body rules such as those in boxing, define the requirements for those pursuits.
• •United Kingdom resuscitation guidance underpins recognising and managing the cardiac arrest that can masquerade as a convulsive seizure.

• •Most people with well-controlled epilepsy can exercise and play sport, and exercise is generally safe and beneficial.
• •A convulsive collapse may be a cardiac arrest: once movements stop, if the athlete is unresponsive and not breathing normally, start cardiopulmonary resuscitation.
• •A single seizure does not always mean epilepsy, and a normal electroencephalogram does not exclude it.
• •Higher-risk sports include swimming, diving, climbing, motor sport and shooting, and some sports such as boxing exclude affected athletes.
• •Common precipitants include missed medication, sleep deprivation and alcohol, with acute causes such as hypoglycaemia.
• •A seizure over five minutes, repeated seizures without recovery, or a seizure after head trauma are emergencies.