RLS and hemifacial spasm

Restless Leg Syndrome
-Urge to move, improved with activity, worse with inactivity (sitting, lying down), worse in the
-Urge is often described as irritating, painful, crawling, uncomfortable. Mainly in calfs >thighs,
much less likely elsewhere.
-Often associated with periodic leg movements of sleep (which is felt to be due to release of
spinal reflexes).
-Hereditary (though genes are unknown)
-Iron deficiency
-Serum ferritin (goal >50) and iron, TSH, CMP.
-Treat iron deficiency/underlying causes, in addition to symptomatic relief.
-First line: Classically dopamine agonists (pramipexole 0.25-0.75mg QHS, ropinorole 0.25-8mg
QHS, or rotigotine 1-3mg); however, this can worsen symptoms over time, so more recently
there is a shift toward gabapentin or pregabalin as first-line (as effective, without worsening of
-Second line: VPA, carbamezapine, clonidine, levodopa.
-Third line: Narcotics (oxycodone for starters, but may even need to escalate to methadone in
severe cases).
-Sleep clinic may be helpful.
Hemifacial Spasm
-Intermittent twitching of muscles innervated by facial nerve; typically occurs in flurries, but can
become tonic over time. 90% of time starts around eye, and spreads to lower face over time.
-Occurs spontaneously, but worse with voluntary movements (have them smile and open/close
eyes repeatedly to elicit), stress, fatigue, or anxiety.
-Can get eyebrow RAISE at time of eyelid closure spasm (specificity for hemifacial spasm is
-More rarely can occur bilaterally, but if so it MUST be asynchronous.
Etiology: Compression of 7th cranial nerve (vascular 94% of time, tumor 4% of time).
Workup: Get MRI brain +/- MRA head to r/o tumor, MS. Don’t treat vascular issues.
DDX: Bell’s, blephrospasm, facial nerve injury, stroke, tics, simple partial seizures, psychogenic.
Tx: Botox is gold standard. Last resort is decompressive surgery (very effective, but is brain