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General Principles
When considering neurological disorders in licence holders, the medical assessor should be mindful of the
following questions:
1. Does the licence holder have neurological disease at all?
2. If there is a static condition, does it functionally compromise flight safety?
3. Does the condition have a progressive temporal profile that can be monitored?
4. Does the condition have the potential for insidious incapacitation?
5. Does the condition have the potential for sudden incapacitation?
6. Has the licence holder recovered from the condition without functionally significant residual
neurological compromise?
History is paramount in assessing neurological conditions, since the neurological examination and indeed
laboratory studies are often normal. To emphasize this principle one need only consider syncope,
migraine, the epileptic with a normal EEG, and the transient ischaemic attack with no cervical bruit or
other finding. History is often the sole means of diagnosis, be it from the licence holder, the witness, the
emergency responder, the medical professional, the medical records, or family and peers. Errors in
aeromedical disposition are commonly rooted in historical inaccuracies.
Another important consideration in the evaluation of neurological fitness is the role of laboratory studies.
The test result must be interpreted in the context of the entire clinical picture. Up to 40 per cent of
epileptic individuals have normal electroencephalograms, and a significant proportion of normal
individuals have false positive tilt table studies. The medical assessor must remain keenly aware of false
positive and false negative laboratory studies.
When considering aeromedical disposition, the medical assessor should adopt an objective approach to
risk assessment. What risk of recurrence is acceptable in an applicant? Incapacitation risk cannot be
ICAO Preliminary Unedited Version — October 2008 III-10-2
reduced to zero since every individual has a risk of a first seizure, or a stroke, for example. After an
increased risk has become apparent because of a neurological event or an investigation result, a decision
has to be made concerning acceptable risk for aviation duty. Acceptable risk is likely to vary depending
on the duty the applicant is licensed to perform. A professional pilot flying single pilot public transport
operations requires a higher level of fitness than a private pilot. In this chapter, the approach has been
taken that a risk of future incapacitation of one per cent per annum is a reasonable maximum risk to
accept for a professional pilot engaged in multi-crew operations, although it is recognized that some
States using objective risk criteria may consider this as too restrictive. However, for States seeking
guidance on such issues, this figure is a reasonable starting point, for which there is considerable
experience in some Contracting States. The topic of risk assessment and flexibility in medical
certification is considered in more detail in Part I, Chapter 2.
A comprehensive review of neurological disorders is not within the scope of this chapter. Neurological
conditions commonly encountered by the medical assessor will be addressed.
In the following text the terms “Operational Implications” and “Aeromedical Considerations” are used.
The former refers to the initial decision concerning fitness to exercise the privileges of a licence, and the
latter refers to a subsequent decision that may be made after further consideration, when time has passed
and/or following appropriate examination and investigation.
Episodic Disorders
By virtue of their ability to cause incapacitation, the episodic disorders are of clear aeromedical
significance. Migraine headache, cluster headache, transient global amnesia, epilepsy, and the isolated
seizure all are represented in the licence holder population, some being commonly encountered. Though
vertigo is often of peripheral (labyrinthine) origin, central vertigo related to brain stem vascular or
demyelinating disease may occur. The medical assessor must determine whether unrestricted certification,
conditional certification, or disqualification is warranted. In general, a risk of sudden incapacitation
exceeding one per cent per year is considered unacceptable for aviation duties of all classes, as well as
safety-sensitive air traffic control duties.
Migraine
Since migraine is common (17 per cent of women, 10 per cent of men), it is a frequent aeromedical
certification issue. There are three varieties of migraine:
1. Common migraine: The headache occurs without aura, and is often but not invariably unilateral.
Clinical features may include a throbbing quality, light and/or sound sensitivity, nausea,
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Manual of Civil Aviation Medicine 2(23)
