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Background The United Kingdom (UK) signed up to the World Health Organisation’s Global Action Intersectoral Plan (IGAP) on epilepsy in 2022, committing to developing a public health response to, and prevention strategy for epilepsy. However, the epidemiology of preventable UK epilepsies has not been studied at scale. We aim to quantify the proportion of epilepsy arising with preventable aetiologies, providing data to contribute to evidence-based strategies.Methods This cohort study included 2.9million individuals without prevalent epilepsy, registered with a Welsh GP on the 2011 census date. Conducted within the Secure Anonymised Information Linkage (SAIL) Databank, between 2011–2024, we used anonymised, linked, coded primary and secondary-care health-data, death records, census and area-level demographic data. Incident cases were assigned aetiologies where aetiology codes preceded or were within one-year of epilepsy diagnosis. Aetiologies were classified hierarchically; as i) genetic, ii) epilepsy-syndromes, iii) non-preventable, iv) mixed, and v) potentially preventable aetiologies (e.g. Infections, brain-injuries).Results We identified 20,730 incident epilepsy cases and classified 70% according to epilepsy aetiologies, substance-misuse disorders, or epilepsy-syndromes.Using hierarchical classification, 431(2%) epilepsy cases were associated with genetic disorders and 2,343(11%) had epilepsy-syndromes. 2,335(11%) cases had non-preventable aetiologies. 426(2%) had mixed aetiologies. 9,073(44%) individuals had ≥1 potentially preventable aetiologies including stroke/cerebrovascular-disease, brain-injuries, dementia, infections; 50% had ≥2 preventable aetiologies. >50% of epilepsy cases occurring with genetic and non-preventable aetiologies, had additional preventable aetiologies.Conclusion This population-based study highlights that a substantial proportion of epilepsy in Wales has only potentially preventable aetiologies, including stroke and brain-injuries, or arises with substance misuse disorders. Ways to address these preventable aetiologies of epilepsy needs further research and implementation in policy. As incident epilepsy frequently occurs with ≥2 preventable aetiologies, optimal prevention strategies may address the wider risk factors for brain-health, or target specific common aetiologies. We should consider how we can better preserve brain-health in all individuals diagnosed with epilepsy.