Aerospace neurology care can help pilots get back in the cockpit


Pilots in cockpit of commercial plane
Pilots are required to follow strict health guidelines per the FAA and must be cleared to fly again following injury or neurological symptoms.

For many pilots, flying is more than a career; it’s part of their identity. Because of that, much of their life revolves around staying fit to be in the cockpit. So, when a pilot is faced with a health challenge that has the potential to ground them temporarily or permanently, it can be devastating.

The Federal Aviation Administration (FAA) has rigorous medical certification standards for pilots because they bear a heavy responsibility for personal and passenger safety. FAA rules prohibit pilots from taking medications that may cause drowsiness, and even some of the most common neurological conditions, such as migraines, concussions, or depression, can jeopardize a pilot’s fitness to fly.

Navigating these requirements can be an arduous and sometimes frustrating process, which is why more pilots have started to seek out neurologists who are familiar with FAA medical fitness rules.

UT Southwestern’s Peter O'Donnell Jr. Brain Institute and Department of Neurology are home to one of the only dedicated aerospace neurology programs in the U.S., and I am among a select few neurologists who regularly provide comprehensive neurologic evaluations and care for civilian pilots. We have cared for more than 300 commercial and private pilots, providing evaluations, general neurology care, and referrals to UT Southwestern specialists in a range of fields from neurosurgery to stroke rehabilitation.

I typically reserve a certain number of appointments each week just for pilots, streamlining tests and shortening their wait for a neurologic exam, so they can get the care they need to get back in the air and feel like themselves again sooner.

High demand in a bustling aviation city

Dallas-Fort Worth is one of busiest aviation hubs in the world, with major airlines (American and Southwest) headquartered here and thousands of planes landing and taking off from DFW International Airport, the second busiest airport in the world, and Dallas Love Field. In addition, DFW has a large military aircraft and helicopter industry. That confluence of commercial, corporate, military, and private aviation creates a need for pilot-specific health care.

I have several friends who are pilots, and after hearing about their medical frustrations I decided to focus my practice on making it easier for pilots to restore their neuropsychological health.

Dr. Alison Leston
Alison Leston, M.D., Ph.D., is a neurologist who serves in several leadership roles in the aerospace neurology industry.

Staying up to date on the latest FAA requirements is critical to this mission, so I actively serve in aerospace neurology industry leadership roles, such as:

  • Vice president of the International Aerospace Neuroscience Consortium, which holds quarterly meetings with the brightest minds in aerospace neurology, most of whom are from the FAA or the U.S. military or similar agencies around the world.
  • Member of the Federal Air Surgeon Neurology Advisory Board, collaborating closely with the physicians who make the final determination on who is fit to fly.
  • Member of the Civil Aviation Medical Association and Aerospace Medical Association.

How our Aerospace Neurology clinic works

Pilots must see an aviation medical examiner (AME) for a mental and physical fitness exam every six months, year, or five years based on their age and the type of aircraft they fly:

  • First-class medical certificates are typically required for airline transport pilots.
  • Second-class is for commercial pilots.
  • Third-class is for private, recreational, and student pilots.
  • There is also a BasicMed option for recreational pilots.

In addition to vision and hearing tests and mental and neurological standards, certification requires pilots to disclose all medical care and medications they’ve taken since their previous AME physical. For example, if they went to urgent care for a concussion or saw a doctor for migraines or depression.

Certain conditions may disqualify a pilot from flying, such as bipolar disorder, epilepsy, substance abuse, or transient loss of consciousness without sufficient explanation of the cause.

If there is any question whether a condition or treatment caused neurological deficits, the AME will not issue the pilot’s flight fitness certification. Instead, the pilot will undergo additional exams or testing, and will typically see me for a comprehensive neurologic exam that will help them meet FAA requirements for flying.

Common conditions we treat

In collaboration with my O’Donnell Brain Institute colleagues, we provide pilots with custom treatment plans for managing neurologic and mental health conditions, such as:


Complex migraines can cause vision problems and debilitating sensitivity to light and sound. The FAA does not allow pilots to take standard medications that can cause drowsiness, so we can guide patients to alternatives such as beta blockers, which were designed to treat high blood pressure and have been shown to prevent migraines without cognitive side effects. MRIs may be required for certain types of migraines to confirm that they are not caused by any other neurological conditions.


Pilots may be restricted from flying for a minimum of six months after a mild concussion or for a year or more for a moderate concussion. We connect patients with O’Donnell Brain Institute specialists in sports neurology and physical medicine and rehabilitation to get specific, FAA-required imaging and tests such as EEGs, MRIs, neuropsychological evaluations, and sleep studies to determine flight fitness. Spatial awareness is vital to pilots who may be flying through the clouds or in poor visibility, so we also refer some pilots to UTSW’s neurotologists in the Department of Otolaryngology to evaluate them for ear conditions that might cause dizziness.

Depression and anxiety

While I do not treat mental health conditions myself, I can streamline referrals to psychologists and psychiatrists at the O’Donnell Brain Institute who can curate effective, FAA-approved treatments to improve patients’ mental health and quality of life.


Nerve damage can arise from systemic conditions such as diabetes or after a traumatic injury. We can help patients restore or manage functional limitations such as numbness, pain, or weakness by recommending safe medications and physical and occupational therapy from our physical medicine and rehabilitation team.

Seizure evaluations

There is a very low threshold to ground pilots who might have had a seizure or an unexplained loss of consciousness. For example, if they faint while donating blood, they will be grounded until an investigation confirms the event was not a seizure or was not caused by a condition that puts them at increased risk of seizures. Our program evaluates pilots after a fainting incident or head injury to determine when or if they are no longer at high risk of developing seizures. We also work with UTSW epileptologists to evaluate pilots to rule out seizures.


As stroke awareness and treatment improves, more patients are surviving with fewer deficits. One to two years after a mild stroke or transient ischemic attack (TIA or mini-stroke), pilots must get a comprehensive neurological exam, blood tests, heart monitoring, and brain imaging to pursue recertification.

Our primary goal is to get pilots effective care and improve their health and quality of life. When they are stable, we can focus on helping them navigate FAA neurologic fitness certification.

After a pilot completes their required tests and exams, they add my neurological report to their medical records and AME flight physical. Then they submit this information with their application to be certified by the FAA, whose doctors determine whether the pilot can safely fly again.

Because of my specialization and our team approach to care, our patients have a better chance of having their application accepted on the first try. However, not every pilot will be able to return to work quickly, which can be a difficult situation. In those cases, we help pilots get the care they need from physical and occupational therapists, surgeons, and other specialists to navigate recovery and set new goals.

Related reading: MEG technology: Improving epilepsy surgery outcomes, one weird helmet at a time

The future of aerospace neurology

Though the niche is small today, aerospace neurology is a growing field. The rate of private plane use is growing, up 20% since the start of the pandemic. And as the population grows older, aging pilots will naturally face more neurologic problems, such as stroke and Parkinson’s disease.

UT Southwestern has amassed a medical database of nearly 300 pilots, and we plan to analyze the data and explore trends in the types of neurologic conditions we see in pilots, identifying which treatments worked best to return them to the cockpit sooner.

The civilian spaceflight industry is also taking off, especially here in Texas. As more people participate in space travel in the years ahead, pre-flight medical screenings will become even more important because civilians may not be as fit to fly as professional pilots and astronauts.

Through my patient relationships and collaboration with international colleagues, our clinic remains on the leading edge of aerospace neurology and is well-positioned for the future. It’s a victory every time we help restore a pilot’s neurologic health, and we consider it our responsibility to help them on their journey.

To request an appointment in our Aviation Neurology clinic, call 214-645-8300 or request an appointment online.