From the Guidelines
To evaluate someone with facial twitching, start with a thorough history and physical examination to exclude identifiable causes of facial paresis or paralysis, as recommended by the 2013 clinical practice guideline: Bell's palsy executive summary 1. When evaluating a patient with facial twitching, it is essential to consider the onset, duration, frequency, and exacerbating factors of the symptoms. Ask about associated symptoms like pain, weakness, or sensory changes, and inquire about medications (particularly neuroleptics, SSRIs, and stimulants), caffeine intake, stress levels, sleep quality, and family history of movement disorders. The physical examination should include a complete neurological assessment with special attention to cranial nerve function, particularly facial nerve (CN VII) integrity, as outlined in the 2022 update of the ACR Appropriateness Criteria for cranial neuropathy 1. Look for other involuntary movements and assess for signs of systemic diseases. Distinguish between common causes like benign fasciculations, hemifacial spasm (unilateral, progressive twitching), blepharospasm (eyelid spasms), facial myokymia (rippling movements), or tardive dyskinesia (medication-induced). Some key points to consider in the evaluation process include:
- The facial nerve (CN VII) is one of the most complex cranial nerves and contains branchial motor, visceral motor, general sensory, and special sensory functions 1.
- The intracranial course of the facial nerve includes pontine, cisternal, and intratemporal segments, and it may be affected by various conditions such as infarction, vascular malformations, tumors, and multiple sclerosis 1.
- Laboratory testing may include electrolytes, calcium, magnesium, and thyroid function, and for persistent or concerning symptoms, consider electromyography (EMG), nerve conduction studies, or brain MRI to rule out structural lesions. The management of facial twitching depends on the underlying cause, but may include addressing precipitating factors, botulinum toxin injections for hemifacial spasm or blepharospasm, or medications like carbamazepine or baclofen for symptomatic relief, as suggested by the clinical practice guideline: Bell's palsy 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Evaluation of Facial Twitching
To evaluate someone for the complaint of facial twitching, several steps can be taken:
- A thorough neurological examination is necessary, including an assessment of the cranial nerves, as outlined in 2.
- The diagnosis of primary hemifacial spasm (pHFS) should be considered, which can be made with delay and may be misdiagnosed as psychogenic spasm, tics, facial myokymia, or blepharospasm, as discussed in 3.
- Electroneuromyographic (ENMG) examination and magnetic resonance imaging (MRI) can be used to aid in the diagnosis of pHFS and to rule out other causes of nerve compression, as mentioned in 3.
- A differential diagnosis should be made to distinguish between pHFS and other conditions, such as post-facial palsy synkinesis, which can be made by ENMG examination and MRI, as discussed in 3.
Treatment Options
Treatment options for facial twitching may include:
- Botulinum toxin injections, which have been shown to be effective in reducing muscle tone and improving passive function in patients with spasticity, as discussed in 4 and 5.
- Botulinum toxin injections may also be effective in treating other symptoms associated with multiple sclerosis, such as bladder detrusor hyperreflexia, tremor, and facial myokymia, as mentioned in 4, 5, and 6.
- However, it is essential to note that the use of botulinum toxin in the treatment of facial twitching should be carefully considered, and the potential side effects, such as muscular weakness, should be taken into account, as discussed in 6.