Medscape is available in 5 Language Editions – Choose your Edition here.


Hemifacial Spasm Differential Diagnoses

  • Author: Steven Gulevich, MD; Chief Editor: Nicholas Lorenzo, MD, MHA, CPE  more...
Updated: May 16, 2016

Diagnostic Considerations

Hemimasticatory spasm

Hemimasticatory spasm is analogous to hemifacial spasm and occurs with irritation to the motor trigeminal nerve. This rare condition is a segmental myoclonus and presents with unilateral involuntary contractions of the trigeminally innervated muscles of mastication (usually the masseter). Similar to hemifacial spasm, hemimasticatory spasm responds to treatment with medications and botulinum toxin. However, less evidence exists that exploratory surgery benefits patients with this condition.[5]

Myoclonic movements

Myoclonic movements affecting facial musculature also may arise from lesions at the brain or brainstem level. These are distinguished from hemifacial spasm by the distribution of abnormal movements (more generalized, possibly bilateral) and possibly by electrodiagnostic evaluation. Imaging studies may yield an underlying cause. Central myoclonus responds to anticonvulsant management.

Oromandibular dystonia

Oromandibular dystonia refers to dystonia affecting the lower facial musculature, predominantly the jaw, pharynx, and tongue. When oromandibular dystonia occurs in conjunction with blepharospasm, the disorder is termed Meige syndrome.

Jaw-opening forms of oromandibular dystonia indicate primary involvement of the digastric and lateral pterygoid. Jaw-closing oromandibular dystonia involves the masseter, temporalis, and medial pterygoid. Jaw deviation, indicating predominant involvement of the lateral pterygoid, is rare.

Botulinum toxin is the preferred treatment for oromandibular dystonia and is most effective in the jaw-closure type. Medications seldom yield acceptable results. When medications must be used, employ the same agents as for blepharospasm.[6] Because of the risk of aspiration, never inject botulinum toxin into the tongue.

Craniofacial tremor

Craniofacial tremor may occur in association with essential tremor, Parkinson disease, thyroid dysfunction, or electrolyte disturbance. It occurs rarely in isolation. Focal motor seizures must occasionally be distinguished from other facial movement disorders, particularly hemifacial spasm. Postictal weakness and greater involvement of the lower face are distinguishing features of focal motor seizures.

Facial chorea

Facial chorea occurs in the context of a systemic movement disorder (eg, Huntington disease, Sydenham chorea). Chorea is a random, flowing, nonpatterned set of movements. A related disorder, spontaneous orofacial dyskinesia of the elderly, is observed primarily in the edentulous. It usually responds to proper fitting of dentures.


Facial tics are brief, repetitive, coordinated, semipurposeful movements of grouped facial and neck muscles. Tics may occur physiologically or in association with diffuse encephalopathy. Some medications (ie, anticonvulsants, caffeine, methylphenidate, antiparkinsonian agents) are associated with producing tics. Single, repetitive, stereotyped movements (eg, repetitive grimacing, throat clearing, vocalizations) define a simple tic disorder.

Facial myokymia

Facial myokymia appears as vermicular twitching under the skin, often with a wavelike spread. This is distinguished from other abnormal facial movements by characteristic electromyogram discharges presenting as brief, repetitive bursts of motor unit potentials firing at 2-60 Hz interrupted by periods of silence of up to a few seconds. Facial myokymia may occur with any brainstem process. Severe cases may benefit from botulinum toxin. Most cases are idiopathic and resolve without treatment over several weeks.

Contributor Information and Disclosures

Steven Gulevich, MD Centennial Medical Center, Colorado

Steven Gulevich, MD is a member of the following medical societies: American Academy of Neurology, Colorado Medical Society

Disclosure: Nothing to disclose.

Chief Editor

Nicholas Lorenzo, MD, MHA, CPE Founding Editor-in-Chief, eMedicine Neurology; Founder and CEO/CMO, PHLT Consultants; Chief Medical Officer, MeMD Inc

Nicholas Lorenzo, MD, MHA, CPE is a member of the following medical societies: Alpha Omega Alpha, American Association for Physician Leadership, American Academy of Neurology

Disclosure: Nothing to disclose.


Stephen A Berman, MD, PhD, MBA Professor of Neurology, University of Central Florida College of Medicine

Stephen A Berman, MD, PhD, MBA is a member of the following medical societies: Alpha Omega Alpha, American Academy of Neurology, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Glenn Lopate, MD Associate Professor, Department of Neurology, Division of Neuromuscular Diseases, Washington University School of Medicine; Director of Neurology Clinic, St Louis ConnectCare; Consulting Staff, Department of Neurology, Barnes-Jewish Hospital

Glenn Lopate, MD is a member of the following medical societies: American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Reference Salary Employment

  1. Abbruzzese G, Berardelli A, Defazio G. Hemifacial spasm. Handb Clin Neurol. 2011. 100:675-80. [Medline].

  2. Yaltho TC, Jankovic J. The many faces of hemifacial spasm: differential diagnosis of unilateral facial spasms. Mov Disord. 2011 Aug 1. 26(9):1582-92. [Medline].

  3. Campos-Benitez M, Kaufmann AM. Neurovascular compression findings in hemifacial spasm. J Neurosurg. 2008 Sep. 109(3):416-20. [Medline].

  4. Moller AR. The cranial nerve vascular compression syndrome: II. A review of pathophysiology. Acta Neurochir (Wien). 1991. 113(1-2):24-30. [Medline].

  5. Cruccu G, Inghilleri M, Berardelli A, et al. Pathophysiology of hemimasticatory spasm. J Neurol Neurosurg Psychiatry. 1994 Jan. 57(1):43-50. [Medline].

  6. Elston JS. The management of blepharospasm and hemifacial spasm. J Neurol. 1992 Jan. 239(1):5-8. [Medline].

  7. Adler CH, Zimmerman RA, Savino PJ, et al. Hemifacial spasm: evaluation by magnetic resonance imaging and magnetic resonance tomographic angiography. Ann Neurol. 1992 Oct. 32(4):502-6. [Medline].

  8. Wang X, Thirumala PD, Shah A, Gardner P, Habeych M, Crammond DJ, et al. Effect of previous botulinum neurotoxin treatment on microvascular decompression for hemifacial spasm. Neurosurg Focus. 2013 Mar. 34(3):E3. [Medline].

  9. Kraft SP, Lang AE. Cranial dystonia, blepharospasm and hemifacial spasm: clinical features and treatment, including the use of botulinum toxin. CMAJ. 1988 Nov 1. 139(9):837-44. [Medline].

  10. Reimer J, Gilg K, Karow A, et al. Health-related quality of life in blepharospasm or hemifacial spasm. Acta Neurol Scand. 2005 Jan. 111(1):64-70. [Medline].

  11. Jannetta PJ, Abbasy M, Maroon JC, et al. Etiology and definitive microsurgical treatment of hemifacial spasm. Operative techniques and results in 47 patients. J Neurosurg. 1977 Sep. 47(3):321-8. [Medline].

  12. Moller AR. The cranial nerve vascular compression syndrome: I. A review of treatment. Acta Neurochir (Wien). 1991. 113(1-2):18-23. [Medline].

  13. Miller LE, Miller VM. Safety and effectiveness of microvascular decompression for treatment of hemifacial spasm: a systematic review. Br J Neurosurg. 2011 Dec 15. [Medline].

  14. Thirumala PD, Shah AC, Nikonow TN, Habeych ME, Balzer JR, Crammond DJ, et al. Microvascular decompression for hemifacial spasm: evaluating outcome prognosticators including the value of intraoperative lateral spread response monitoring and clinical characteristics in 293 patients. J Clin Neurophysiol. 2011 Feb. 28(1):56-66. [Medline].

  15. Ma Q, Zhang W, Li G, Zhong W, Yang M, Zheng X, et al. Analysis of therapeutic effect of microvascular decompression surgery on idiopathic hemifacial spasm. J Craniofac Surg. 2014 Sep. 25(5):1810-3. [Medline].

  16. Mauriello JA, Leone T, Dhillon S, et al. Treatment choices of 119 patients with hemifacial spasm over 11 years. Clin Neurol Neurosurg. 1996 Aug. 98(3):213-6. [Medline].

  17. Jankovic J, Schwartz K, Donovan DT. Botulinum toxin treatment of cranial-cervical dystonia, spasmodic dysphonia, other focal dystonias and hemifacial spasm. J Neurol Neurosurg Psychiatry. 1990 Aug. 53(8):633-9. [Medline]. [Full Text].

  18. Colosimo C, Chianese M, Giovannelli M, et al. Botulinum toxin type B in blepharospasm and hemifacial spasm. J Neurol Neurosurg Psychiatry. 2003 May. 74(5):687. [Medline].

All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.