The increased rate of SUDEP during the night is likely multifactorial involving both situational factors, such as being without a witness and prone, and physiological changes due to the influence of sleep and circadian rhythms. These possible explanations for the nocturnality of SUDEP are not mutually exclusive. Lastly, there are circadian changes to physiology during the night which might facilitate SUDEP. Sleep typically happens at night and seizures which emerge from sleep might be more dangerous. Being prone in the accouterments of a bed during the postictal period might impair breathing and increase SUDEP risk. Patients are more likely to be prone on a bed following a nocturnal seizure. During the night, seizures are more likely to be unwitnessed therefore, it is less likely that another person would be able to administer a lifesaving intervention. These factors fall into four categories: influences of (1) being unwitnessed, (2) lying prone in bed, (3) sleep-wake state, and (4) circadian rhythms. There are a number of factors which might contribute to the nighttime predilection of SUDEP. The aim of this review is to discuss evidence from patient cases, clinical studies, and animal research which is pertinent to the nocturnality of SUDEP. It is consistently observed that SUDEP happens more during the night and the early hours of the morning. Convergent lines of evidence suggest that SUDEP occurs due to seizure induced perturbation of respiratory, cardiac, and electrocerebral function as well as potential predisposing factors. Sudden unexpected death in epilepsy (SUDEP) is the leading cause of epilepsy-related death in patients with refractory epilepsy.
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