Narcolepsy: Pathophysiology, Diagnosis, Management, and Future Directions, a Narrative Review

To critically synthesize the current understanding of narcolepsy's pathophysiology, diagnostic challenges, and treatment landscape, and to articulate the emerging paradigm shift from symptomatic management toward disease modification.

This narrative review is based on a strategic search of literature from PubMed and Google Scholar published between 2015 and 2025, focusing on disease mechanisms, diagnosis, and established and emerging therapeutic interventions.

Narcolepsy is a neurological disorder fundamentally driven by an irreversible loss of hypocretin-producing neurons, a process strongly linked to an autoimmune response in individuals with the HLA-DQB1*0602 allele. Despite this well-defined pathophysiology, diagnosis is often delayed by nearly a decade due to limited physician awareness and symptom overlap with a wide range of psychiatric and metabolic comorbidities. Current pharmacological strategies, while providing partial relief from excessive daytime sleepiness and cataplexy, are purely symptomatic and fail to address the core hypocretin deficiency. The field is now at a critical inflection point, with promising research into hypocretin receptor agonists, targeted immunotherapies, and neuromodulation techniques poised to directly address the underlying pathology.

The existing therapeutic approach to narcolepsy is palliative, not restorative, leaving a significant unmet need for interventions that can alter the disease's natural history. The future of narcolepsy management depends on translating novel pathophysiological insights into disease-modifying therapies. Achieving this requires a concerted effort to accelerate diagnosis, validate new clinical endpoints, and prioritize the development of interventions capable of restoring neurological function. Such an approach holds the potential to move beyond symptom suppression and fundamentally improve the lives of individuals with narcolepsy.