CEREBROSPINALECTOMYThey just approved the first drug that fixes the actual cause of narcolepsy. The most common side effect is insomnia. Five of these. Every one of them has happened. Which one did you not believe the first time? SAVE this for the next time someone says neurology is guesswork. They just approved the first drug that fixes the actual cause of narcolepsy. The most common side effect is insomnia. We didn't cure it. We overshot it. Locums week, small hospital. A man set an MRI on the desk. Me: "Whose is this?" Him: "Duke's." Me: "Is Duke a person?" Him: "Duke is a very good boy." Veterinary neurology is its own board-certified specialty with its own residency. I am not it. I told him that. He did not seem to accept it. Team: "His pupils are different sizes — should we scan him?" Me, holding up his driver's license from 2011: "They were different sizes here, too." Psych: "First psychotic break, twenty-four years old." Me: "Any seizures? Any fever? Any strange mouth movements?" Psych: "...why?" Me: "Because sometimes the psychiatry consult is an antibody." ER: "Facial droop, twenty-nine, nothing else wrong with him." Me: "Has he been outside?" ER: "...it is August." Me: "Then that is a yes, and I want the tick question asked out loud." Late summer, a young adult, an isolated facial palsy, and a tick-endemic zip code. The season is part of the differential, which is why the calendar hangs where I can see it.
EXPLAINED (ACCURACY-CHECKED)
(1) The FDA approved oveporexton (ORZEYFUL) on Aug 5, 2026 — the first oral orexin receptor 2 agonist — for narcolepsy type 1, targeting the underlying orexin signaling deficit. The most common adverse events in the pivotal trials were insomnia and urinary urgency/frequency. (2) Veterinary neurology is a separate board-certified specialty (ACVIM, neurology specialty); physician neurologists are not trained or credentialed to interpret veterinary imaging. (3) Benign physiologic anisocoria is common (present in roughly one in five people) and is stable over time; comparing old photographs is a standard bedside method for establishing that a pupillary asymmetry is chronic. (4) Anti-NMDA receptor encephalitis classically presents with prominent psychiatric symptoms, seizures, and orofacial dyskinesias, and is confirmed by antibody testing — it can initially be mistaken for a primary psychiatric presentation. (5) Lyme neuroborreliosis is a recognized cause of peripheral facial nerve palsy, particularly in endemic regions and with a marked seasonal (late spring through summer) distribution; bilateral facial palsy is a classic presentation.
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