Letter to the Editor: At Face Value: Obama and Neurology

Hemifacial spasm is characterized by intermittent involuntary twitching of muscles of the face, which is usually unilateral.^1,2 The prevalence is about 10/100,000, occurring more commonly in women (2:1) with onset typically between the second and eighth decades of life with an average between 45-50 years of age.

Although a diagnosis based upon a video is not a substitute for a careful history and neurological examination, in numerous television interviews over three years with close-up views, President Barack Obama appears to have frequent involuntary muscle twitching of the right side of his face just inferior to the right orbit.^3-7

The twitching is consistent with hemifacial spasm. In a health summary released by his presidential campaign on May 29, 2008,⁸ his internist described him as being in excellent health without any mention of hemifacial spasm. I am unaware of any mention by the President about this facial twitching although there is one media report, that I believe is incorrect, of a “chronic facial tic.”⁹ In contrast to hemifacial spasm, a motor tic is an arrhythmic, rapid, stereotyped movement that resembles normal, coordinated movement.¹ A person with a tic can usually voluntarily reproduce and transiently suppress the movements. Examples of simple motor facial tics include blinking, eye rolling, grimacing, and mouth opening.

Many patients with hemifacial spasm are unaware of their condition. Hemifacial spasm is usually due to compression of the facial nerve at its exit zone in the brainstem by blood vessels (anterior inferior cerebellar artery, the posterior inferior cerebellar artery, the vertebral artery, or combinations of two of these arteries ). About five percent of cases have a prior history of Bell's palsy. Rare causes include tumors (epidermoid, neuroma, astrocytoma of the cerebellopontine angle, meningioma, and parotid), Chiari I malformation, and cysticercosis which can be excluded with a magnetic resonance imaging scan of the brain.

progresses to involve additional facial muscles with uncommon spontaneous remissions. Treatment with medications including carbamazepine, clonazepam, phenytoin, gababentin, and baclofen is often of limited or no benefit. Microsurgical vascular decompression is usually curative, although there is a risk of various complications (including hearing loss and facial weakness) and recurrence. Botulinum toxin injections are often the preferred treatment with longterm safety and good to excellent improvement in 76- 100 percent of patients.

—Randolph W. Evans, MD Houston, TX

1. Shannon KM. Hemifacial spasm. In: Gilman S, editor. MedLink Neurology. San Diego: MedLink Corporation. Available at www.medlink.com. Accessed 12/02/09.
2. Kenney C, Jankovic JM. Botulinum toxin in the treatment of blepharospasm and hemifacial spasm. J Neural Transm 2008;115:585–591.
3. Meet the Press. 10/22/06. NBC News. (was available on www.youtube.com when letter initially prepared but recently removed and not available on NBC site)
4. Barbara Walters Special: Barack Obama Interview. 11/26/08. abc News. (was available on www.youtube.com when letter initially prepared but recently removed and available for sale only on abc site).
5. 60 Minutes. President Obama. 3/22/09. CBS News. Available at http://www.cbsnews.com/video/watch/?id=4883166n&tag=topHome;topStory
6. Nightline. 7/23/09. abc News. Available at ttp://www.youtube.com/watch?v=RiYCle98xj0
7. 60 Minutes. President Obama. 9/13/09. CBS News. Available at http://www.cbsnews.com/video/watch/?id=5307949n&tag=cbsnewsSidebarArea.0
8. Obama Health Summary. 5/29/08. Available at http://firstread.msnbc.msn.com/archive/2008/05/29/1076277.aspx
9. “Changing of the guard. Stress takes toll on Obama, develops chronic facial tic Michelle said to be distraught over spasms under right eye.” WorldNetDaily. Posted 11/29/08. Available at http://www.wnd.com/?pageId=82364

Editor's Note:Presidential health has become a matter of public record in recent years as Commanders-in-Chief and even presidential candidates have issued health records and regular health status reports. There is also significant historical interest in the health of presidents, from speculation about Thomas Jefferson's affliction with migraines (Headache.2006;46:492-497), JFK's Addison's Disease, the impact of Ronald Reagan's Alzheimer's, to emerging suggestions that FDR actually died of cancer (FDR's Deadly Secret.In press, Due Jan. 2010).

Please note that Dr. Evans has investigated footage dating back at least three years—prior to Mr. Obama's attaining the presidency—in his assessment of the President's involuntary muscle twitch. This contradicts some observations in the non-medical media of a “tic” developing in the past few months.