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Alright, 14-year-old, night-time full-body twitching with headache history, ADHD/autism, on methylphenidate (propranolol held). Normal basic bloods. Here are 3 solid differentials you’d be expected to think of:
1️⃣ Nocturnal seizures (esp. myoclonic or focal motor epilepsy)
Big one to rule out.
Why it fits
“Full body twitching” → could be generalised myoclonic jerks
Occurring at night → seizures often cluster in sleep / on waking
Adolescence = peak age for juvenile myoclonic epilepsy (JME)
Headaches → could be post-ictal or comorbid migraine
Neurodiversity slightly ↑ epilepsy risk
Clues to ask for
Tongue biting, incontinence
Confusion after episodes
Morning jerks dropping things
Family history of epilepsy
👉 Needs EEG ± sleep-deprived EEG
2️⃣ Functional neurological disorder (FND) / functional movement disorder
Already hinted in the note — and common in teens.
Why it fits
Adolescent girl (peak demographic)
Whole-body movements that may look dramatic
Occurs in bed but not clearly stereotyped like seizures
Normal investigations so far
Headache history (functional symptoms often cluster)
Autism/ADHD → higher FND prevalence
Suggestive features
Variable pattern between episodes
Eyes tightly shut during events
Stops with distraction or suggestion
No post-ictal phase
Diagnosis is positive, not exclusion-only.
3️⃣ Medication-related movement disorder (stimulant-induced)
Very relevant here.
Methylphenidate can cause:
Tics
Myoclonus
Exacerbation of underlying movement disorders
Sleep disruption → worsens physiological jerks
Why it fits
Known trigger
Night = when fatigue unmasks abnormal movements
ADHD/autism patients have higher baseline tic risk
Also consider:
Propranolol withdrawal tremor (if recently stopped)
Interaction between sleep deprivation + stimulant
Trial of dose review / drug holiday can be diagnostic.
🌙 Other good “honourable mentions” (less likely but exam points)
| Condition | Why |
|---|---|
| Hypnic jerks | Benign sleep-onset jerks; usually brief, not repetitive |
| Periodic limb movement disorder | Rhythmic limb jerks in sleep |
| Migraine with brainstem aura | Rarely movement phenomena |
| Anxiety/panic nocturnal attacks | Can mimic shaking |
🚩 Red flags pushing toward epilepsy
Stereotyped episodes
Injury during events
Cyanosis/apnoea
Post-event sleepiness
Occurs from sleep repeatedly
🧠 Most likely trio in this case
Nocturnal seizures (JME or focal motor epilepsy)
Functional movement disorder (FND)
Methylphenidate-related movement/tic disorder
If you want, I can give a quick “seizure vs FND” bedside comparison table — that’s usually what examiners love next.
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