Reversible Hemifacial Spasm after Starting Escitalopram.

This is a case of a patient who developed hemifacial spasm after he was started on escitalopram. His symptoms got worse after the dose was increased. The spasm resolved after the medication was stopped gradually. This is an unreported adverse effect of escitalopram or any selective serotonin reuptake inhibitor.

Case Presentation

A 50-year-old male was seen in the neurology clinic for episodes of left eyelid twitching. These episodes started 2 weeks before his visit and each episode would last for about 5 min separated by 1–3 h. This eyelid twitching was painless, uncontrollable and with no urge. The patient was not sure if it persisted during sleep or not but he was never awoken by it. These movements were embarrassing to the patient and affecting his social life. The patient had no twitching in the rest of his face or body. He had no double vision, pain or dizziness.

The patient was diagnosed with a mood disorder 2 weeks before his visit and was started on 5 mg of escitalopram once daily to be increased to 10 mg once daily after a week. No further details were available regarding his mood disorder as this was done in a different medical center.

He noticed an increase in intensity and frequency after increasing the dose of escitalopram to 10 mg daily. He was not known to have any medical illness and was not taking any other medications.

On examination, the patient had a spell in the neurology clinic. There was repetitive forceful left eye closure associated with elevation of the left eyebrow and minimal mouth deviation to the left.

The spell lasted for a few minutes, then subsided. His neurological examination was unremarkable in between the spells. This includes normal extraocular movements, facial sensation and muscle movements, balance, coordination and gait.

The patient was assessed by a psychiatrist and it was felt that he does not need to be on a medication for his mood disorder. Escitalopram was reduced to 5 mg for 1 week then was discontinued.

The patient was then seen in follow-up 6 months later and he reported that the spells stopped 2–3 months after stopping the drug.

On a phone follow-up 16 months after the original visit, the patient reported that there had been no recurrence of these spells.

No relevant investigations were done for this patient.

Discussion

Hemifacial spasm are defined as involuntary, irregular clonic or tonic movements of muscles innervated by the facial nerve. It is usually unilateral and sporadic and usually starts around the eye [1]. It affects mainly the middle-aged population with an incidence rate of about 11 cases for every 100,000 individuals [2].

It may be primary (mainly caused by vascular loop compression at the root exit zone of the facial nerve) or secondary due to brainstem damages as in stroke or multiple sclerosis, facial nerve injury or late complication of Bell's palsy [3].

Escitalopram is a selective serotonin reuptake inhibitor (SSRI) and the S-enantiomer of racemic citalopram. It is used most commonly in the treatment of depression and anxiety [4].

The overall incidence rate of side effects is not very common in patients treated with escitalopram 10 mg per day but the incidence increases in patients treated with 20 mg per day. The most common reported side effects are headache, insomnia, diarrhea, somnolence, dizziness and lethargy in addition to dry mouth, increased sweating, constipation, fatigue, and indigestion [5, 6].

Serotonin syndrome has been reported with SSRIs (including escitalopram) as monotherapy, but it usually occurs with the concomitant use of other serotonergic drugs or drugs that impair serotonin metabolism [7].

SSRIs are rarely associated with abnormal movement (extrapyramidal symptoms) such as acute dystonia, dyskinesia, and parkinsonism or worsening pre-existing Parkinson disease [8].

In a report published in 1996, 71 cases of SSRI were associated with extrapyramidal symptoms. The most common symptoms were akathisia followed by dystonia, parkinsonism and tardive dyskinesia [9].

In our case, there was a clear temporal association between the onset of the hemifacial spasm and the introduction of escitalopram which became more noticeable after increasing the dose. This was confirmed when the spasm intensity started to regress after withholding escitalopram, then completely disappeared without recurrence after the medication was stopped.

These movements were not felt to be tics as the patient's age was not typical and there was no urge or relief after these movements. They were also not felt to be blepharospasms as they were unilateral, and the eyebrow was moving up with each twitch. They were not felt to be focal seizures given the frequency and the lack of evolution beyond the eyelids.

To our knowledge, this has not been reported before, but there is a case report of escitalopram-induced paroxysmal dystonia where the patient developed paroxysmal cervical-cranial dystonia after receiving escitalopram for a few days. These were expressed as cervical and oral contracture with sustained and painful laterocollis and twisting tongue movements. These episodes resolved without recurrence after escitalopram was discontinued [10].

Conclusion

To our knowledge, this is the first reported case of reversible hemifacial spasm related to SSRI intake that resolved after the medication was discontinued.

Statement of Ethics

The patient has given his written informed consent to publish this case. He was informed that his name, videos or pictures will not be published.

Disclosure Statement

The author declares no conflict of interest.

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Funding Sources

None.