Purpose: To examine trends in reporting injury as a cause of death among people with epilepsy in the U.S. during the past three decades. Method: We analyzed the U.S. multiple causes of death data from death certificates in 1981-2010 to compare rate and odds ratios (OR) of reporting injury as cause of death among cases with vs. without mention of epilepsy across years. Results: The trends in reporting epilepsy with and without injury were similar in most age groups but were inconsistent in most external causes of injury. The OR of reporting injury was 1.02 (95% confidence intervals (Cl) 0.97-1.07) in 1981-1985 and decreased to 0.52 (95% CI 0.48-0.55) in 2006-2010. The decline in OR was prominent among people aged 15-24 followed by people aged 25-44. For the five external causes of injury, the OR of suffocation and drowning were 6.32(95% CI 5.91-6.75) and 5.64(95% CI 5.16-6.16) in 1981-1985 and decreased to 3.03 (95% CI 2.74-3.35) and 2.56 (95% CI 2.18-3.00) in 2006-2010. The OR for poisoning and traffic crashes were 0.70(95% Cl 0.57-0.85) and 0.08 (95% CI 0.07-0.09) in 1981-1985 and 0.21 (95% Cl 0.18-0.25) and 0.06 (95% CI 0.05-0.08) in 2006-2010. Conclusion: The risk of fatal injury among people with epilepsy decreased drastically during the past three decades in most age groups and for most external causes of injury except falls. People with epilepsy had lower risks of dying from injury due to poisoning or traffic crashes, had higher risks of dying from suffocation and drowning. (C) 2014 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.