A 54-year-old right-handed woman was seen in our clinic regarding the possibility of Parkinson disease. One year earlier, she had experienced the onset of a right hand tremor that had mainly been present at rest but had spontaneously improved before her clinic visit. Also, her speech had become softer during the past year, and certain activities, such as eating or walking, were slower than before. She had noted no change in speed or ability to perform other activities, including the use of utensils, personal hygiene, and getting dressed or undressed. Writing had become extremely "sloppy" but not micrographic. She had experienced 3 falls, 1 as a result of tripping over an object and 2 from losing her balance while walking downhill. She had been treated for depressive symptoms with paroxetine (10 mg/d) for 8 months, with some improvement in her mood. The paroxetine therapy had been discontinued 3 months earlier. She was hospitalized 2 months after her initial clinic visit and had in the interim developed more of a nasal quality to her voice; dysphagia, which was more prominent with liquids than solids; and vomiting 2 or 3 times per week. She also admitted to a mild headache, which was holocephalic, steady, and pressurelike in quality and occurred only when she coughed. Standing up did not precipitate her headaches, but lying down could make them less intense. She also reported episodic fatigue and having been "uptight" and making mistakes at work 2 to 3 years earlier. Also, in retrospect, she checked some notes that she had taken years earlier and found that she had experienced a sensation of a "plugged" left ear 1 day after doing a handstand in a swimming pool and had headaches 4 days later. The following year, in addition to having difficulty at work, she had again noted a sensation of plugged ears. She had no visual, vertiginous, or autonomic symptoms; she had no history of head or neck trauma; and she had never had a lumbar puncture. Her only medication was alprazolam (0.25 mg nightly). There was a history of a tremor in her father, a paternal aunt, and 2 cousins. Her medical history was remarkable for breast cancer 5 years earlier, for which she had undergone a left mastectomy and had subsequently been treated with tamoxifen citrate, with no evidence of recurrence.