Clinical reasoning: a 16-year-old girl with fixed unilateral grimace.

Jeff Waugh, MD, PhD Sanjay P. Prabhu, MBBS Blaise Bourgeois, MD Sanjeev Kothare, MD SECTION 1 A 16-year-old girl was referred from the epilepsy clinic for urgent admission to the long-term EEG monitoring unit. She had a prior history of both epileptic and nonepileptic seizures of multiple types, but presented to the clinic for evaluation of a new type of movement, present for 1 month. Over that time period her home antiseizure regimen (levetiracetam and topiramate) had been serially increased with no relief. She described (and demonstrated) a tonic spasm of the right lower face which had a sudden onset and lasted 30–90 seconds. In retrospect, her parents reported small facial twitches which preceded the full-blown spasms by 2 months. These spells appeared to worsen with stress and attention. Short episodes were not painful, but as the episodes became more frequent she developed progressively worsening masseter pain. On the day of admission, she experienced these spasms every 5–10 minutes, more frequently during the examination. Between episodes, her neurologic examination had normal results, with no sensory or motor changes to the face. The video on the Neurology Web site at www.neurology.org provides an example.