Restless Leg Syndrome -Urge to move, improved with activity, worse with inactivity (sitting, lying down), worse in the evening. -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). Etiologies: -Hereditary (though genes are unknown) -Neuropathy -Iron deficiency -Uremia -Pregnancy -Hypothyroid -caffeine Workup: -Serum ferritin (goal >50) and iron, TSH, CMP. Tx: -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 symptoms). -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 100%) -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 surgery).