What are the treatment options for facial dyskinesias?

Treatment Options for Facial Dyskinesias

Carbamazepine or oxcarbazepine are the first-line treatments for facial dyskinesias, particularly for paroxysmal kinesigenic dyskinesia (PKD), with over 85% of patients achieving complete remission at low doses. 1

Types of Facial Dyskinesias

• Facial dyskinesias can present as dystonia (most common), chorea, ballism, or a combination, often manifesting as face twitching, rigidity of facial muscles, and dysarthria 1
• Paroxysmal kinesigenic dyskinesia (PKD) is a specific type affecting approximately 70% of patients with facial involvement 1
• Tardive dyskinesia is an involuntary movement disorder typically affecting the orofacial region associated with long-term use of dopamine receptor-blocking agents 2

First-Line Pharmacological Treatment

• Sodium channel blockers are highly effective for PKD, with carbamazepine and oxcarbazepine being the preferred options 1
• Low-dose carbamazepine (50-200 mg/day) or oxcarbazepine (75-300 mg/day) achieves complete remission in more than 85% of PKD patients 1
• Initial dosage recommendations:
  • Adults: Start carbamazepine at 50 mg or oxcarbazepine at 75 mg 1
  • Children: Start carbamazepine at 1 mg/kg and titrate gradually 1

Second-Line Treatment Options

• For patients who cannot tolerate carbamazepine or have HLA-B*15:02 (risk of Stevens-Johnson syndrome), alternative sodium channel blockers include 1:
  • Lamotrigine
  • Topiramate
  • Phenytoin sodium

Treatment for Tardive Dyskinesia

• If clinically feasible, gradually withdraw the offending antipsychotic medication 2, 3
• Consider switching to atypical antipsychotics with lower D2 affinity when antipsychotic therapy must be continued 2, 3
• Regular monitoring using the Abnormal Involuntary Movement Scale (AIMS) every 3-6 months is essential 2

Botulinum Toxin Therapy

• Botulinum toxin injections have shown long-term efficacy for facial dyskinesias including blepharospasm, hemifacial spasm, and Meige syndrome 4
• In a seven-year study of 50 patients, complications were transient, minimal, and well-tolerated 4
• Patients who do not respond to medication withdrawal may still have good response to botulinum toxin treatment 5

Special Considerations

• HLA-B*15:02 screening should be implemented before initiating carbamazepine treatment, particularly in Han Chinese populations, to reduce the risk of adverse cutaneous reactions 1
• Take medication at bedtime to minimize adverse effects like dizziness 1
• Individualize dosage based on patient response and tolerance - some patients may tolerate auras without attacks, while others require complete symptom relief 1
• PKD is generally a benign disease with natural remission, so treatment decisions should consider the patient's age, attack frequency and severity, psychological impact, and personal preference 1

Drug-Induced Facial Dyskinesias

• When facial dyskinesias are drug-induced, discontinuation of the offending medication should be considered 5
• Three of seven patients in one study showed improvement after discontinuing the suspected causative drug 5
• For patients who cannot discontinue medication or don't improve after discontinuation, botulinum toxin injections are recommended 5