From sleep complaints to clinical phenotypes: A tiered assessment and integrated management framework for sleep comorbidities in Epilepsy—A narrative review

Sleep disorders are among the most common but frequently underestimated comorbidities in patients with epilepsy, with major manifestations including insomnia, obstructive sleep apnea, excessive daytime sleepiness, restless legs syndrome, and periodic limb movements of sleep. A complex bidirectional interaction exists between epilepsy and sleep disorders: sleep deprivation, disrupted sleep architecture, and sleep-disordered breathing may increase seizure susceptibility, whereas nocturnal seizures, interictal epileptiform discharges, antiseizure medications, and mood comorbidities may further impair sleep continuity and daytime alertness. Although mechanistic links and individual sleep disorders have received increasing attention, a practical outpatient pathway that connects sleep-related complaints with screening, phenotype recognition, objective testing, and subsequent intervention remains insufficiently defined. From a clinical phenotyping perspective, this review proposes a complaint-based framework for the identification, tiered assessment, and integrated management of sleep comorbidities in epilepsy. The framework translates common sleep complaints into major actionable phenotypes, including insomnia, obstructive sleep apnea, restless legs syndrome/periodic limb movements of sleep, excessive daytime sleepiness, and overlap phenotypes, while incorporating life-course and syndrome-specific considerations for children and adolescents, young adults, middle-aged adults, patients with juvenile myoclonic epilepsy, and older adults with epilepsy. This review organizes dispersed evidence on sleep and epilepsy into a clinically oriented conceptual framework linking complaint-based entry, tiered assessment, phenotype-specific intervention, and follow-up reassessment. The framework is intended to facilitate recognition and structured clinical reasoning, while its feasibility and effects on patient outcomes require prospective evaluation.