Eyelid Myokymia

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Article initiated by:

Terry.Henry, Bhakti Panchal, MD, Nikisha Q. Richards, MD, FACS

All contributors:

Terry.Henry, Nikisha Q. Richards, MD, FACS, Michael T Yen, MD, Bhakti Panchal, MD

Assigned editor:

Rona Z Silkiss, MD FACS

Review:

Assigned status Up to Date

 by Michael T Yen, MD on August 28, 2025.

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Eyelid myokymia is the most common form of facial myokymia and presents as spontaneous, fine, rippling contractions of the orbicularis oculi muscle, typically affecting the lower eyelid unilaterally. Although usually benign and self-limited, it may occasionally persist or be mistaken for more serious conditions such as hemifacial spasm or essential blepharospasm. This article summarizes the current understanding of eyelid myokymia, including its pathophysiology, risk factors, and clinical presentation. It also reviews the differential diagnosis and provides guidelines for evaluation, patient education, and indications for referral.

Disease Entity

Disease

Eyelid myokymia is an involuntary, fine, rippling contraction of the orbicularis oculi muscle, typically unilateral and more common in the lower eyelid [1]. Contractions are continuous but non-forceful, and generally self-limited. Unlike voluntary or reflexive eyelid closure, these contractions are spontaneous and localized. It is commonly mistaken for hemifacial spasm, which is forceful and often involves broader facial musculature. [1]

Etiology

The exact cause of eyelid myokymia is incompletely understood. Most cases are idiopathic, though proposed triggers include anxiety, fatigue, and stress. Certain medications have been associated, including clozapine, flunarizine, topiramate, gold salts, and, in isolated case reports, metformin. [1–5]

Risk Factors

- Caffeine consumption

- Anxiety or psychological stress

- Sleep deprivation

- Prolonged screen time [2]

- Post-viral infection [3]

- Certain medications: clozapine, flunarizine, topiramate, gold salts, metformin [1,4,5]

Pathophysiology

Eyelid myokymia results from asynchronous discharges within the orbicularis oculi muscle, producing semi-rhythmic bursts. Single motor units may fire several times per second at a frequency of 3–8 Hz. Discharges occur spontaneously but may be exacerbated by voluntary movement. [6,7]

Primary Prevention

Although no specific preventive therapy exists, lifestyle modifications such as stress reduction, improved sleep hygiene, and decreased caffeine and alcohol intake can reduce symptoms. [8]

Diagnosis

History

Patients typically present with unilateral eyelid twitching. A thorough history should assess precipitating factors such as stress, fatigue, alcohol and caffeine intake, smoking, lifestyle changes, viral illness, and medication use.

Physical Examination

When present, examination may reveal fine, repetitive contractions of the eyelid, often in the lower lid. Gentle distraction of the eyelid may temporarily reduce symptoms. Contractions can occasionally produce subtle globe movements [7].

Signs

Unilateral, fine, involuntary contractions of the eyelid are typical, though bilateral or upper lid involvement can occur.

Symptoms

Patients often report localized eyelid twitching. Associated fatigue, anxiety, or stress may be noted when symptoms are precipitated by lifestyle or environmental factors.

Clinical Diagnosis

Eyelid myokymia is a clinical diagnosis based on characteristic eyelid contractions not initiated by voluntary movement. Symptoms that persist for weeks, spread beyond the eyelid, or are associated with neurological signs should prompt further evaluation.

Diagnostic Procedures

There are no specific laboratory or diagnostic tests for eyelid myokymia.

Laboratory Test

Ancillary studies (MRI or CT) may be warranted in persistent or atypical cases to exclude underlying neurological disease.

Differential Diagnosis

- Hemifacial spasm

- Essential blepharospasm

- Meige syndrome

- Spastic–paretic facial contracture

Management

General Treatment

Eyelid myokymia is usually benign and self-limited, resolving within minutes to weeks. Initial management consists of reassurance and elimination of potential triggers (stress, fatigue, caffeine, alcohol, or offending medications). [1]

Medical Therapy

Persistent cases (> several weeks) should prompt referral to an Oculofacial plastic surgeon or neuro-ophthalmologist. Neuroimaging may be indicated to exclude multiple sclerosis [9], brain tumors [10–12], or brainstem pathology [13].

For refractory symptoms, botulinum toxin injections may be considered, typically providing symptom relief for 3–4 months. [14]

Medical Follow-up

Patients with resolution may follow up as needed. Persistent or progressive cases warrant specialist evaluation.

Surgery

Surgery is not indicated for eyelid myokymia. Rarely, myectomy has been performed for intractable cases. [15]

Surgical Follow-up

Surgical patients should maintain oculofacial plastic follow-up for monitoring.

Complications

Eyelid myokymia itself is benign. Complications typically indicate an alternative or coexisting diagnosis, requiring appropriate neurologic or ophthalmic evaluation.

Prognosis

The prognosis is excellent. Most cases resolve spontaneously. Chronic or recurrent episodes are rare but typically benign.

References

1. Khalkhali M. Topiramate-Induced Persistent Eyelid Myokymia. Case Rep Psychiatry. 2016;2016:7901085. doi:10.1155/2016/7901085.
2. Gunes IB. Association Between Eyelid Twitching and Digital Screen Time, Uncorrected Refractive Error, Intraocular Pressure, and Blood Electrolyte Imbalances. Cureus. 2024;16(9):e69249. doi:10.7759/cureus.69249.
3. Khan HA, Shahzad MA, Jahangir S, et al. Eyelid Myokymia—A Presumed Manifestation of Coronavirus Disease 2019 (COVID-19). SN Compr Clin Med. 2022;4(1):29. doi:10.1007/s42399-021-01094-w.
4. Ahsan M, Nizami DJ. Metformin-Induced Eyelid Myokymia. Indian J Pharmacol. 2024;56(5):358-360. doi:10.4103/ijp.ijp_284_24.
5. Medrano-Martínez V, Pérez-Sempere A, Moltó-Jordá JM, et al. Eyelid Myokymia in Patients with Migraine Taking Topiramate. Acta Neurol Scand. 2015;132(2):143-146. doi:10.1111/ane.12395.
6. Rubin M, Root JD. Electrophysiologic Investigation of Benign Eyelid Twitching. Electromyogr Clin Neurophysiol. 1991;31(6):377-381. PMID:1935763.
7. Miller NR. Eyelid Myokymia. Surv Ophthalmol. 2011;56:277-278.
8. Jafer Chardoub AA, Patel BC. Eyelid Myokymia. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025–. Available from: https://www.ncbi.nlm.nih.gov/books/NBK560595/
9. Banik R, Miller NR. Chronic Myokymia Limited to the Eyelid is a Benign Condition. J Neuroophthalmol. 2004;24(4):290-292.
10. Barmettler A, Dinkin MJ, Lelli GJ. Eyelid Myokymia: Not Always Benign. Orbit. 2011;30(6):289-290. doi:10.3109/01676830.2011.556306.
11. Ito E, Sugita R, Saito R. Eyelid Myokymia Caused by a Trigeminal Schwannoma as Determined by the Trigeminal-Evoked Blink Reflex. Clin Case Rep. 2023;11(3):e7086. doi:10.1002/ccr3.7086.
12. Kitaguchi Y, Sabundayo MS, Kakizaki H. Eyelid Myokymia with Concomitant Cerebral Tumour: A Case Report. Neuroophthalmology. 2017;42(3):150-152. doi:10.1080/01658107.2017.1350195.
13. Kakouri A, Chen Y, McCulley TJ. Isolated Hemifacial Spasm as the Presenting Sign of Cerebral Glioblastoma. Ophthalmic Plast Reconstr Surg. 2025;41(2):e71-e73. doi:10.1097/IOP.0000000000002838.
14. Shome D, Jain V, Natarajan S. Ptosis Caused by Orbicularis Myokymia and Treated with Botulinum Toxin: A Case Report. Eye. 2007;21:444-445. doi:10.1038/sj.eye.6702617.
15. Jordan DR, Anderson RL, Thiese SM. Intractable Orbicularis Myokymia: Treatment Alternatives. Ophthalmic Surg. 1989;20(4):280-283.