eMedicine Specialties > Neurology > Electromyography and Nerve Conduction Studies

Myokymia

Suying Song, MD, Assistant Professor, Department of Neurology, New York University School of Medicine

Updated: Oct 6, 2009

Introduction

Background

Myokymia, a form of involuntary muscular movement, usually can be visualized on the skin as vermicular or continuous rippling movements.

The word myokymia was used first more than 100 years ago, when Schultze described continuous, slow, undulating muscular contractions in small muscles of hands and feet.¹ Kny used the term myoclonus fibrillaris multiplex to describe similar clinical manifestations.² For the past century, different authors applied the term myokymia to different involuntary muscular movements. Most of them showed electromyographic (EMG) evidence of spontaneous group discharges. This led to tremendous confusion in conceptually defining this particular clinical entity and its electrophysiologic features.

Pathophysiology

The clinical phenomenon is characterized by its classic quivering movement of the involved muscle without movement of the joint. Myokymia can be seen in muscles innervated by cranial or spinal nerves. The distribution can be either regional or generalized, depending on the etiology. Also, it can be seen transiently in healthy subjects after strenuous exercise.

The exact mechanism(s) of myokymia is not well understood. Myokymia of the facial muscles is believed to originate from the facial nucleus or from some contribution by a supranucleus process; however, the presence of myokymia in polyradiculopathy indicates the possibility of a more distal generator. Most authors agree that myokymia in other parts of the body is generated by distal motor axons, either by a primarily axonal process or by segmental demyelination with secondary axonal dysfunction. Some have postulated that transaxonal ephaptic excitation occurs peripherally after focal nerve damage leads to formation of an artificial synapse.

Myokymia is believed to be associated with generation of spontaneous activity, including myokymialike discharge in the dystrophic mouse whose nerve root axons have no Schwann-cell enwrapment. By this mechanism, spontaneous discharge could initiate volleys of activity or afferent fibers could directly stimulate efferent fibers in the vicinity of the lesion and produce a self-perpetuating reverberating circuit.

The central nervous system's electrotonic spread of discharge from rhythmic generators toward anterior horn cells also might play a role in generation of the spontaneous discharge. Each patient may have a different operating mechanism, depending on the particular areas involved and the different etiologies. The fact that patients with Isaacs syndrome respond dramatically to treatment of myokymia with phenytoin and/or carbamazepine³ suggests a possible abnormality of the potassium channel in this particular entity.

Frequency

United States

Although myokymia can be seen in patients with different neurological and medical conditions and occasionally even in healthy subjects, it is a relatively rare clinical manifestation.

Mortality/Morbidity

• Most of the diseases associated with myokymia are not life threatening.
• The prognosis is solely dependent upon the underlying etiologies.
• Myokymia is considered benign when detected in patients after strenuous exercise.

Clinical

History

• Patients with myokymia may present with symptoms of pain, cramps, spasms, weakness, stiffness, or twitching.
• Sensory symptoms are reported rarely, unless the underlying etiology(ies) includes sensory nerve involvement.
• Typical myokymic discharges also can be seen in the EMGs of patients referred for totally unrelated complaints.

Physical

• Facial myokymia
  • Affected muscles show slow, undulating, fine movements on the surface of the skin due to activation of the most superficial muscle layers. Facial weakness can be present in the involved muscles.
  • EMG study shows typical myokymic discharges of spontaneous, rhythmic/semirhythmic bursts of normal-appearing potentials of 30-60 Hz. The bursts of each group of potentials are followed by a period of silence, with subsequent repetition of grouped discharges of identical potentials. The spontaneous activities are not altered by voluntary activation of the muscles.
• Focal or segmental myokymia
  • These types of myokymia commonly are seen in the limbs or particular segmental level(s). Physical findings mostly are related to the underlying etiology(ies), which is usually asymptomatic and not a major concern of the patient.
  • EMG study shows myokymic discharges similar to those recorded in facial myokymia.
• Generalized myokymia
  • A triad of myokymia, muscular stiffness, and decreased deep tendon reflexes was first described by Isaacs in 1961; it also is called Isaacs syndrome.⁴
    • Muscle weakness and atrophy and excessive sweating are frequently associated features. Smooth muscles and cardiac muscles typically are spared.
    • Sensory symptoms are rarely present.
    • The muscular stiffness is different than that seen in myotonia, both clinically and electrodiagnostically. Although both can be exacerbated by cold, myokymia can be detected when the muscle is at rest and during sleep. Patients with myotonia are normal at rest; the stiffness is induced by mechanical stimulation.
  • The myotonic discharge recorded by EMG ceases upon relaxation of the muscle, while spontaneous grouped discharges of myokymia persist for some time, well above the abnormal pattern that was present before the voluntary contraction.
    • The EMG features encountered in patients with generalized myokymia include the previously described typical myokymic discharge or neuromyotonia, which has a much higher frequency of discharges (up to 300 Hz).
    • Generalized myokymia in other clinical entities shares less consistent clinical manifestations.

Causes

• Facial myokymia
  • This type of myokymia is seen more commonly than other types.
  • Facial myokymia has been reported to be associated with inflammatory demyelinating diseases, brainstem neoplasms, Guillain-Barré syndrome, or other intramedullary pontine lesions. Facial myokymia also has been reported in patients with history of radiotherapy, with findings similar to those of more common brachial or lumbar radiation plexopathies.
• Focal or segmental myokymia
  • The majority of patients with a history of radiation therapy have myokymic discharges detected within the field of radiation. Metastatic lesions generally are believed to be less likely to generate myokymia. The amount of radiation ranges widely, though myokymia rarely is reported with radiation doses less than 10 gray (Gy).
  • Electrodiagnostic findings are usually consistent with plexopathy. Other less common causes include acute or chronic inflammatory polyradiculoneuropathy⁵ (with or without coexistent systemic vasculitis), ischemic or traumatic focal neuropathy, entrapment neuropathy, polyradiculopathy secondary to torticollis, syringomyelia, and chronic idiopathic plexopathy.
  • Transient myokymia, described in the calf or hand muscles, was reported after brief strenuous exercise. It usually resolves spontaneously over weeks to months.
• Isaacs syndrome
  • Generalized myokymia is one of the cardinal features of Isaacs syndrome, which is a rare clinical entity with no known common etiologies. Congenital and acquired forms are described.
  • The acquired form has been associated with neoplasms, thymoma, myasthenia gravis, lymphomas, and a variety of autoimmune nervous system disorders.
  • Spinal anesthesia and peripheral nerve block fail to abolish the myokymic discharges. Blocking the motor end plate transiently terminates the spontaneous activities. Evidence from muscle and nerve biopsies also favors a neurogenic origin.
  • Generalized myokymia also can be seen in patients with systemic illnesses (eg, thyrotoxicosis, uremia) and following binge consumption of alcohol, exposure to toxins, timber rattlesnake bite, gold therapy, and penicillamine therapy.
  • One case of myokymia as an initial and predominant manifestation of dermatomyositis has been reported.

Differential Diagnoses

Other Problems to Be Considered

Blepharospasm
Facial myoclonus
McArdle disease
Meige syndrome
Myotonic diseases
Spasticity
Tetanus

Workup

Laboratory Studies

Complete blood count, chemistry, creatine kinase, thyroid testing group, sedimentation rate, Lyme titer, Venereal Disease Research Laboratory (VDRL) test, and rheumatology screening are the basic laboratory tests for all patients with clinical myokymia. Serum alcohol level and toxic screen are recommended for acute onset of generalized myokymia.

Imaging Studies

Neuroimaging studies with CT scan or MRI usually are performed for certain regions after careful examination and in cases in which electrodiagnostic studies have localized a lesion to a particular area. For example, if facial myokymia is confirmed, MRI study of the brain with special attention to posterior fossa is ordered to search for an anatomic lesion. Imaging studies are not otherwise necessary for establishing the diagnosis of myokymia.

Other Tests

Nerve conduction velocity (NCV) and EMG studies are necessary to qualify and quantify neurogenic/myogenic dysfunction.

• NCV can detect the presence of plexopathy, mononeuropathy, and polyneuropathy (axonal or demyelinating).
• EMG can confirm the presence of myokymic discharges or neuromyotonia. The specific findings of myokymia in EMG examination are detailed in the Physical section.
• EMG study also can document the presence of neurogenic/myogenic dysfunction and its distribution.
• Information obtained through these studies serves as a guide for further diagnostic investigation. Serial studies can objectively document the evolution of the myokymia.

Procedures

Lumbar puncture with examination of cerebrospinal fluid (CSF) usually is performed for patients with documented acute or chronic polyradiculoneuropathy, central nervous system demyelinating disorder, or other suspected inflammatory, infectious, or neoplastic processes.

Treatment

Medical Care

Treatment of myokymia is focused largely on the underlying etiology. Most patients with facial or focal limb myokymia are not particularly disturbed by the myokymia itself. The accompanying symptoms of the particular neurological or medical conditions are the major concern to patients and their caretakers.

• For conditions secondary to thyrotoxicosis, poisoning, and alcoholic cramp syndrome, the myokymia disappears with resolution or improvement of the medical conditions.
• Patients with radiation plexopathy require no intervention.
• Myokymia seen in acute or chronic polyradiculoneuropathy usually improves with immunomodulatory therapy.
• Transient myokymia that develops after strenuous exercise resolves spontaneously over weeks to months.

Activity

No particular activity restriction is imposed on a patient with myokymia. For patients with stiffness and painful cramps, conditioning of muscles by range of motion and isometric exercise is helpful.

Medication

Phenytoin and carbamazepine have been proven to be effective in treating patients with generalized myokymia, specifically patients with continuous muscle fiber activity described by Isaacs syndrome. High therapeutic drug levels usually are required to reach satisfactory control of symptoms. EMG can objectively document the disappearance of myokymic discharges. Other medications, such as benzodiazepines, have been tried with no consistent benefit. Monitoring of potential adverse effects of phenytoin and carbamazepine and precautions for these drugs are no different from when they are used to treat epilepsy.

Antiepileptic agents

These agents prevent seizure recurrence and terminate clinical and electrical seizure activity.

Phenytoin (Dilantin)

Has promising results in patients with Isaacs syndrome. Relieves cramps and pain of involved muscles. EMG can document objective resolution of myokymic discharges. Mechanism of action possibly related to its effect on sodium channel.
Dosage adjusted according to blood level. Target level should be at high therapeutic range.

Dosing

Adult

100-200 mg PO tid

Pediatric

10-15 mg/kg/d PO in divided doses

Interactions

Amiodarone, benzodiazepines, chloramphenicol, cimetidine, fluconazole, isoniazid, metronidazole, miconazole, phenylbutazone, succinimides, sulfonamides, omeprazole, phenacemide, disulfiram, ethanol (acute ingestion), trimethoprim, and valproic acid may increase toxicity
Barbiturates, diazoxide, ethanol (chronic ingestion), rifampin, antacids, charcoal, carbamazepine, theophylline, and sucralfate may decrease effects
May decrease effects of acetaminophen, corticosteroids, dicumarol, disopyramide, doxycycline, estrogens, haloperidol, amiodarone, carbamazepine, cardiac glycosides, quinidine, theophylline, methadone, metyrapone, mexiletine, oral contraceptives, valproic acid

Contraindications

Documented hypersensitivity; sinoatrial block; second- and third-degree AV block; sinus bradycardia; Adams-Stokes syndrome

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Rapid IV infusion may result in death from cardiac arrest, marked by QRS widening
Perform blood counts and urinalyses when therapy is begun and at monthly intervals for several months thereafter to monitor for blood dyscrasias; discontinue use if skin rash appears and do not resume use if rash is exfoliative, bullous, or purpuric; caution in acute intermittent porphyria and diabetes (may elevate blood glucose); discontinue use if hepatic dysfunction occurs

Carbamazepine (Tegretol)

Has promising results in patients with Isaacs syndrome. Relieves cramps and pain of involved muscles. EMG can document objective resolution of myokymic discharges. Mechanism of action possibly related to its effect on sodium channel.
Dosage adjusted according to blood level. Target level should be at high therapeutic range.

Dosing

Adult

200-400 mg PO tid

Pediatric

10-15 mg/kg/d PO in divided doses

Interactions

Danazol may increase serum levels significantly within 30 days of coadministration (avoid whenever possible); do not coadminister with MAOIs; cimetidine may increase toxicity, especially if taken in first 4 wk of therapy; may decrease primidone and phenobarbital levels (their coadministration may increase carbamazepine levels)

Contraindications

Documented hypersensitivity; history of bone marrow depression; MAOIs within last 14 d

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Do not use to relieve minor aches or pains; caution with increased intraocular pressure; obtain CBCs and serum iron at baseline prior to treatment, during first 2 months, and yearly or every other year thereafter; can cause drowsiness, dizziness, and blurred vision; caution while driving or performing other tasks requiring alertness

Follow-up

Prognosis

Prognosis is related directly to the underlying etiology. Myokymia is reversible with successful treatment of the cause.

Miscellaneous

Medicolegal Pitfalls

• Keep in mind that myokymia is a clinical manifestation of many medical and neurological conditions. When myokymia is detected, a search for the potential causes needs to be performed based on distribution of the myokymia, associated symptoms and signs, and other factors.
• Medical treatment with antiepileptic drugs is indicated only for patients with disabling symptoms. The antiepileptics used in myokymia have potentially life-threatening adverse effects. Therefore, clear documentation of the need for treatment and the process of monitoring potential adverse effects is important.

References

1. Schultze F. Beitrage zur Muskelpathologie. Deutsch Z Nervenheilk. 1895;6:65-167.

2. Kny E. Ueber ein dem Paramyoclonus multiplex (Friedreich) nahestehendes Krankheitsbild. Arch Psychiat Nervenkr. 1888;19:577.

3. Jackson DL, Satya-Murti S, Davis L, Drachman DB. Isaacs syndrome with laryngeal involvement: an unusual presentation of myokymia. Neurology. Dec 1979;29(12):1612-5. [Medline].

4. Isaacs H. A syndrome of continuous muscle-fibre activity. J Neurol Neurosurg Psychiat. 1961;24:319-325.

5. Daube JR, Kelly JJ, Martin RA. Facial myokymia with polyradiculoneuropathy. Neurology. May 1979;29(5):662-9. [Medline].

6. Alapati A, Glaussen G, Oh SJ. Myokymia as an initial and predominant manifestation of dermatomyositis. AAEM Abstracts. 1999;95.

7. Albers JW, Allen AA, Bastron JA, Daube JR. Limb myokymia. Muscle Nerve. Nov-Dec 1981;4(6):494-504. [Medline].

8. Andermann F, Cosgrove J, Lloyd-Smith DL. Facial myokymia in multiple sclerosis. Brain. 1961;84:31-44.

9. Brick JF, Gutmann L, McComas CF. Calcium effect on generation and amplification of myokymic discharges. Neurology. Jun 1982;32(6):618-22. [Medline].

10. Denny-Brown D, Foley JM. Myokymia and the benign fasciculation of muscular cramps. Trans Assoc Am Physicians. 1948;61:88-96.

11. Gardner-Medwin D, Walton JN. Myokymia with impaired muscular relaxation. Lancet. Jan 18 1969;1(7586):127-30. [Medline].

12. Greenhouse AH, Bicknell JM, Pesch RN, Seelinger DF. Myotonia, myokymia, hyperhidrois and wasting of muscle. Neurology. Mar 1967;17(3):263-8. [Medline].

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14. Hudson AJ, Brown WF, Gilbert JJ. The muscular pain-fasciculation syndrome. Neurology. Nov 1978;28(11):1105-9. [Medline].

15. Isaacs H. Continuous muscle fibre activity in an Indian male with additional evidence of terminal motor fibre abnormality. J Neurol Neurosurg Psychiatry. Apr 1967;30(2):126-33. [Medline].

16. Isaacs H, Frere G. Syndrome of continuous muscle fibre activity. Histochemical, nerve terminal and end-plate study of two cases. S Afr Med J. Aug 10 1974;48(38):1601-7. [Medline].

17. Lance JW, Burke D, Pollard J. Hyperexcitability of motor and sensory neurons in neuromyotonia. Ann Neurol. Jun 1979;5(6):523-32. [Medline].

18. Lublin FD, Tsairis P, Streletz LJ, et al. Myokymia and impaired muscular relaxation with continuous motor unit activity. J Neurol Neurosurg Psychiatry. Jun 1979;42(6):557-62. [Medline].

19. Lutschg J, Jerusalem F, Ludin HP, et al. The syndrome of 'continuous muscle fiber activity.'. Arch Neurol. Apr 1978;35(4):198-205. [Medline].

20. Matthews WB. Facial myokymia. J Neurol Neurosurg Psychiatry. Feb 1966;29(1):35-9. [Medline].

21. Medina JL, Chokroverty S, Reyes M. Localized myokymia caused by peripheral nerve injury. Arch Neurol. Aug 1976;33(8):587-8. [Medline].

22. Parry-Jones NO, Stephens JA, Taylor A, Yates DA. Myokymia, not myotonia. Br Med J. Jul 30 1977;2(6082):300. [Medline].

23. Roth G. The origin of fasciculations. Ann Neurol. Dec 1982;12(6):542-7. [Medline].

24. Solimena M, Folli F, Denis-Donini S, et al. Autoantibodies to glutamic acid decarboxylase in a patient with stiff-man syndrome, epilepsy, and type I diabetes mellitus. N Engl J Med. Apr 21 1988;318(16):1012-20. [Medline].

25. Valenstein E, Watson RT, Parker JL. Myokymia, muscle hypertrophy and percussion "myotonia" in chronic recurrent polyneuropathy. Neurology. Nov 1978;28(11):1130-4. [Medline].

26. Wallis WE, Van Poznak A, Plum F. Generalized muscular stiffness, fasciculations, and myokymia of peripheral nerve origin. Arch Neurol. May 1970;22(5):430-9. [Medline].

27. Welch LK, Appenzeller O, Bicknell JM. Peripheral neuropathy with myokymia, sustained muscular contraction, and continuous motor unit activity. Neurology. Feb 1972;22(2):161-9. [Medline].

28. Williamson E, Brooke MH. Myokymia and the motor unit. A histochemical study. Arch Neurol. Jan 1972;26(1):11-6. [Medline].

Keywords

myokymia, myoclonus fibrillaris multiplex, myokymic discharges, neuromyotonia, Isaacs syndrome, involuntary muscular movement, facial myokymia, focal myokymia, segmental myokymia, generalized myokymia

Contributor Information and Disclosures

Author

Suying Song, MD, Assistant Professor, Department of Neurology, New York University School of Medicine
Suying Song, MD is a member of the following medical societies: American Academy of Neurology and American Association of Neuromuscular and Electrodiagnostic Medicine
Disclosure: Nothing to disclose.

Medical Editor

Carmel Armon, MD, MSc, MHS, Professor of Neurology, Tufts University School of Medicine; Chief, Division of Neurology, Baystate Medical Center
Carmel Armon, MD, MSc, MHS is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Association of Neuromuscular and Electrodiagnostic Medicine, American Clinical Neurophysiology Society, American College of Physicians, American Epilepsy Society, American Medical Association, American Neurological Association, American Stroke Association, Massachusetts Medical Society, Movement Disorders Society, and Sigma Xi
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Neil A Busis, MD, Chief, Division of Neurology, Department of Medicine, Head, Clinical Neurophysiology Laboratory, University of Pittsburgh Medical Center-Shadyside
Neil A Busis, MD is a member of the following medical societies: American Academy of Neurology and American Association of Neuromuscular and Electrodiagnostic Medicine
Disclosure: Nothing to disclose.

CME Editor

Selim R Benbadis, MD, Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, University of South Florida School of Medicine, Tampa General Hospital
Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Nicholas Y Lorenzo, MD, Chief Editor, eMedicine Neurology; Consulting Staff, Neurology Specialists and Consultants
Nicholas Y Lorenzo, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Neurology
Disclosure: Nothing to disclose.

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