A crucial element of the surgical treatment of medically refractory epilepsy is to delineate cortical areas that must be spared in order to avoid clinically relevant neurological and neuropsychological deficits post-operatively. For each patient, this typically necessitates determining the language lateralization between hemispheres and language localization within hemisphere. Understanding cortical language systems is complicated by two primary challenges: the extent of the neural tissue involved, and the substantial variability across individuals, especially in pathological populations. We review the contributions made through the study of electrophysiological activity to address these challenges. These contributions are based on the techniques of magnetoencephalography, intracerebral recordings, electrical cortical stimulation, and the electro-video analyses of seizures and their semiology. We highlight why no single modality alone is adequate to identify cortical language systems and suggest avenues for improving current practice.