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• Epilepsy can be burdensome for patients, families, health systems, and society. • Health disparities of people with epilepsy can be worsened by living in rural areas. • Demographics and socioeconomic status drive the poor outcomes, not rurality per se. • Prospective studies with standard definitions of rural are needed. Epilepsy is a leading cause of global disease burden, with people with epilepsy (PWE) experiencing adverse health outcomes related to the psychiatric comorbidities and socioeconomic consequences of the disorder. Rural populations are more likely to be impoverished or uninsured, which could impact health outcomes for rural-dwelling PWE (RPWE). This systematic literature review identified original research studying health disparities and outcomes among RPWE in the United States and Canada to (1) characterize the disparities faced by RPWE and (2) elucidate the effects of these disparities upon clinical outcomes. We performed a systematic search of six electronic databases: Pubmed, Cochrane, PsychInfo, Web of Science, Scopus, and Ovid. Articles considered were original research reports conducted in Canada or the United States before August 2020. A modified Newcastle Ottawa Scale was used to assess the quality of the included studies. Our search returned 2093 articles that examined the health disparities of RPWE, of which six met criteria for this review. Outcome measures of health disparity included in these papers were mortality (2; 33%), use of health resources (2; 33%), and epilepsy prevalence (2; 33%). Only one paper (16%) concluded that RPWE experienced worse health outcomes relative to urban-dwelling PWE, while 5 (84%) found no difference. Our study did not find sufficient evidence that RPWE in the US and Canada experience significant health disparities compared to similar urban populations of PWE. More research using prospective studies and datasets allowing better characterization of rurality is required. [ABSTRACT FROM AUTHOR]