The economic impact of epilepsy in the USA and other countries has been well documented in terms of direct treatment-related costs. The average annual direct cost of the disease in the USA is typically estimated by comparing the use and cost of healthcare services in large representative samples of people with an epilepsy diagnosis to similar people without epilepsy using claims or medical billing data. The latest studies, reviewed recently by Begley and Durgin [1], indicate that the average individual with epilepsy and commercial or Medicaid coverage (all ages, genders, seizure types and severity) experiences excess epilepsy-related annual costs in a range between $7659 and $11 354 in 2013 dollars. Only a few of these studies provide separate cost estimates for subpopulations among those with epilepsy, such as individuals with intractable epilepsy. This is problematic for understanding the economic impact of epilepsy because of the variability in how the disease affects people and the effectiveness of existing treatments. As noted in an Institute of Medicine report, ‘Epilepsy is a spectrum of disorders – the epilepsies – with a range of severities, widely differing seizure types and causes, and varying impacts on individuals and their families’ [2]. The existing studies of direct costs in the intractable population reviewed here, though limited in number and methodological rigor, suggest that they are substantially higher than in the general population, but there is no consensus on how much higher.