The rapid rollout of mRNA-based COVID-19 vaccines, including Pfizer-BioNTech's BNT162b2 and Moderna's mRNA-1273, has been instrumental in curbing the pandemic, demonstrating high efficacy and safety in the general population. However, concerns regarding neurological adverse effects, particularly in individuals with epilepsy (PWE), warrant scrutiny. Clinical data from case reports, multicenter studies, and meta-analyses (encompassing over 3000 PWE) indicate that most tolerate vaccination well, with seizure worsening in approximately 5% of cases, often transient and lower than post-COVID-19 infection rates. Rare severe events, such as status epilepticus, highlight vulnerabilities, though background seizure incidence remains comparable or lower than natural rates. This review examines potential neuroimmune mechanisms linking mRNA vaccination to seizure exacerbation, emphasising immune activation, neuroinflammation, and epileptogenesis. mRNA vaccines utilise lipid nanoparticles (LNPs) to deliver spike protein-encoding mRNA, eliciting robust immune responses. Potential triggers for seizures include cytokine storms (e.g., IL-1β, TNF-α, IL-6), blood-brain barrier (BBB) disruption, molecular mimicry with neuronal antigens, and autoantibody production, which may heighten neuronal hyperexcitability in susceptible individuals. Neurological side effects, including Bell's palsy, transverse myelitis, and herpes zoster reactivation, are more prevalent in mRNA platforms, potentially tied to LNP-induced inflammation or cross-reactive immunity. While evidence supports vaccination benefits outweighing risks for PWE, gaps persist in understanding individual predispositions. Future research should prioritise longitudinal studies, EEG monitoring, and AI-driven approaches for personalised risk assessment, mRNA optimisation, and pharmacovigilance. Integrating multi-omics and computational modelling could enhance vaccine safety, ensuring equitable protection for vulnerable populations.
