Research on hyponatremia during mountain marathons is scarce. The present study aimed to investigate the prevalence of exercise-associated hyponatremia during a 44-km trail running race that reached an altitude of 2780 m (Olympus Marathon). Sixty-two runners (five women) who completed the race participated in the study (age: 34.4 ± 8.6 years; height: 1.77 ± 0.06 m; and weight: 75.3 ± 10.0 kg). Anthropometric characteristics, blood, and urine samples were collected pre- and post-race. Food and fluid intake were recorded at each checkpoint. Due to race regulations, the runners could not carry any additional food and fluids besides the ones provided at specific checkpoints. Five runners (8%) exhibited asymptomatic hyponatremia (serum sodium <135 mmol∙L−1). Serum sodium in the hyponatremic runners decreased from 138.4 ± 0.9 (pre) to 131.4 ± 5.0 mmol∙L−1 (post), p < 0.05. Plasma osmolality increased only in the eunatremic runners (pre: 290 ± 3; post: 295 ± 6 mmol∙kg−1; p < 0.05). Plasma volume decreased more in the hyponatremic compared to eunatremic runners (−4.4 ± 2.0 vs. −3.2 ± 1.4%, p < 0.05). Lastly, dietary sodium intake was lower in the hyponatremic runners compared to eunatremic (789 ± 813 vs. 906 ± 672 mg; p < 0.05). The incidence of hyponatremia among the athletes was relatively low, possibly due to race conditions.