Hemifacial spasm (HFS) is a condition, characterized by frequent involuntary contractions of facial muscles on one side of the face. These contractions, appear as if the muscle is twitching and is commonly called tics. Hence, the condition is commonly known as ‘tic convulsif’. Facial nerve passes beneath the ear and reaches various parts of the face to control the facial muscles. Compression of the facial nerve can commonly result in hemifacial spasm. Causes of hemifacial spasm can be many and thorough understanding of individual condition can help in planning appropriate management for hemifacial spasm.
Hemifacial spasm is considered as a neuromuscular disorder, where the problem arises in the nerve and is presented through muscular contractions or muscle twitching. The involuntary muscle twitching or tics in hemifacial spasm is often a result of stimulation of the facial nerve that supplies to the areas of face. Various muscles are supplied by this nerve; so when the nerve is damaged, compressed or irritated in some way, it can produce symptoms of hemifacial spasm. In some people, a specific pattern may be noted regarding the muscle contractions or tics and may appear to originate in one set of muscles and gradually progress. In many others, there may not be any obvious pattern and the involuntary muscle twitching in hemifacial spasm may occur in any muscle supplied by the affected nerve.
Although, hemifacial spasm may not be a painful or severe condition, it can cause varying degrees of discomfort. The person experiencing hemifacial spasm often feel uncomfortable and when tics persist continuously, it may also become socially embarrassing. Severe cases of hemifacial spasm can be more troublesome and may need advanced care and treatment. However, it is also important to rule out other conditions that may mimic the symptoms of hemifacial spasm; hence proper history taking and detailed investigation may be required. Having an understanding about hemifacial spasm can help a lot in dealing with the condition and help to manage hemifacial spasm in a better way.
Causes of Hemifacial Spasm
Hemifacial spasm is basically originated from damage to the facial nerve and manifests itself with symptoms that appear to affect the facial muscles. The commonest causes of hemifacial spasm include damage to the facial nerve.
Facial Nerve Injury can Cause Hemifacial Spasm
Facial nerve exits the skull deep behind the ear region, where it bifurcates into its facial branches. The area is located beneath the ear and is in close proximity to the base of the skull and the initiation of the cervical spine. This region is exposed and can be commonly at a greater risk of injuries, which can injure the facial nerve and cause hemifacial spasm. Injuries or trauma to this region can commonly occur during sports, due to direct blow over the neck and ear region, or a fall causing nerve injury. Car accidents, rear or front end collisions and whiplash, too can commonly cause hemifacial spasm. In whiplash, the neck may speedily move back and front with jerking and the sudden acceleration and deceleration can cause damage to the structures around the neck and the ear region. Facial nerve located in this area can get injured and such injury can cause hemifacial spasm. Other causes of hemifacial spasm may include brainstem injuries or disorders like stroke or multiple sclerosis, which too can cause facial nerve compression.
Hemifacial Spasm Can be Caused Due to Nerve Compression from Artery
Another common cause of facial nerve compression is a blood vessel near the brainstem, exerting pressure over the facial nerve. The most commonly involved blood vessel is a small artery, anterior inferior cerebellar artery, which can compress the facial nerve at the brainstem.
Bell’s Palsy – A Cause of Hemifacial Spasm
Bell’s palsy is a condition, in which the facial nerve gets damaged causing paralysis of the facial nerve. In this, the control of facial muscles is lost and other functions like taste and formation of tears in the eyes are also affected. As it damages the facial nerve resulting in lack of muscle control, it can cause hemifacial spasms on the affected side. It usually affects one side of the face, however both sides of the face can be affected.
Tumor Can Cause Hemifacial Spasm
Any lesion, growth or tumor in the region, through which the facial nerve passes, can compress the facial nerve. This irritates the facial nerve, which too can cause hemifacial spasm.
While exact causes of hemifacial spasms may not be known in some cases, it is considered that some kind of irritation of facial nerve often results in hemifacial spasm. When no obvious cause of hemifacial spasm is found, it may be considered as idiopathic.
Symptoms of Hemifacial Spasm
Hemifacial spasm often presents with symptoms that are easily noticeable and can be noted by observing the facial movements. Hemifacial spasm commonly affects people during their middle ages, women being more prone to experience this condition. Symptoms of hemifacial spasm occurring due to injury can occur at any age, depending on the cause and severity of the condition. When hemifacial spasm is experienced in young people, multiple sclerosis may be suspected. Usually symptoms of hemifacial spasm are seen on the affected side, i.e. the side on which the nerve is irritated, but in some cases, both sides may show symptoms of facial muscle twitching.
Common symptoms of hemifacial spasm include muscular contractions or twitching muscles of the face, particularly on one side. Muscle twitching and symptoms of hemifacial spasm, in most cases, may begin around the lower eyelid and gradually extend to the muscles of the entire eye. Muscle twitching may then slowly spread over the lower part of the face, involving the lower lips. Muscles of the cheeks and upper lip are also gradually involved. Persons experiencing hemifacial spasm often complain of a feeling as if the lower lip is being pulled to one side towards the neck. Eventually, the entre face may get involved showing muscle twitching and symptoms of hemifacial pain.
Symptoms of hemifacial spasm may be aggravated by certain triggering factors. These generally include stress, anxiety or sometimes sudden jerks to the face, head and neck. Overuse of facial muscles like talking, reading, singing, sneezing or yawning are also known to worsen the symptoms of hemifacial spasm.
Depending on the cause of hemifacial spasm and involvement of other areas as when associated with other injuries or medical conditions, additional symptoms may be present. Some people may experience changes in the sensation over the cheeks, jaws and may sometimes feel a burning sensation. Sometimes, complaints of tingling and numbness in the face may be noted, depending on the cause of hemifacial spasm. Some people may experience dryness of eyes and mouth as associated symptoms of hemifacial spasm. People who are experiencing hemifacial spasm in a post paralytic situation, may show symptoms of weakness of facial muscles. This may make facial movements difficult, frowning, smiling and chewing or sometimes swallowing can be difficult.
Diagnosis of Hemifacial Spasm
Diagnosis of hemifacial spasm can be made using a combined approach, which includes history taking, clinical examination and some investigations, as appropriate. While it is necessary to diagnose hemifacial spasm, it may be difficult to differentiate the symptoms of hemifacial spasm from other associated conditions. In such cases, additional investigations may be considered to rule out other possible conditions and confirm any associated medical problems.
Physician takes a complete history, which can reveal any recent injuries to the head, face or neck area. People involved in sports, or those who have experienced a blow, fall or accidents need to be questioned about the details of their event. It is also important to note the details since when the symptoms of hemifacial spasm began and associated symptoms. It may reveal any obvious cause of hemifacial spasm, in some cases. The nature of muscle twitching and the way in which the complaints progressed must be studied. Any previous injuries, history of surgeries or any associated medical conditions are often enquired about.
Clinical examination for the diagnosis of hemifacial spasm may include checking the muscle strength of the facial muscles and their function. The sensory and motor functions of the facial nerve may be studied. Muscle twitching in hemifacial spasm are noted, their pattern and the affected sides are considered. Symmetry of face is studied and the affected side is compared to other side of the face to understand the condition of hemifacial spasm. Various tests may be performed or signs may be elicited by the doctor to assess these factors. Neurological examination and checking for certain reflexes are considered by the physician to help the diagnosis of hemifacial spasm.
Investigations for hemifacial spasm include:
Electromyogram (EMG) – This test helps to study the activity of the facial muscles, when the muscles is at rest and when it is stimulated. It can help to diagnose hemifacial spasm. When the facial nerve is stimulated, it can show relevant changes and contractions in the facial muscles and the same are recorded. It may be done with nerve studies to find the exact cause of hemifacial spasm and the involvement of the nerve.
Nerve Conduction Study (NCS) – This helps to study the pattern and conduction of signals through the facial nerve, which can help to understand the way in which it affects the facial muscles. Changes in the nerve conduction are recorded, based on which it is possible to confirm the diagnosis of hemifacial spasm.
Scans – CT scan and MRI of the brain may be considered, if the possible causes of hemifacial spasm seem to be related to injuries or conditions of the brain. These scans can help to detect any abnormality of blood vessel, tissue or nerve damage, aneurysm, any growth or tumor in the brain area. If involvement of the neck is suspected, scans of the neck region may be ordered, as appropriate.
Angiogram – If involvement of the blood vessel or compression of the facial nerve due to an artery is suspected or to detect an aneurysm. An angiogram may be performed to confirm the diagnosis of hemifacial spasm or to plan further surgical treatment, in some cases.
Other tests may be required to rule out other conditions that may appear like hemifacial spasms. Tests to rule out stroke, multiple sclerosis, etc. may be considered, if appropriate.
Treatment of Hemifacial Spasm
Treatment for hemifacial spasm includes medications, injections and in certain cases, which do not respond well to any treatment, surgical options may be considered.
Medical Management for Hemifacial Spasm
Medications are effectively used for treatment of hemifacial spasm. These include
- Muscles relaxants, which help to relax the overstrained and over stimulated muscles, thus providing some relief in involuntary muscle twitching.
- Anti-convulsant medicines are also used to treat hemifacial spasm, as these help to block the pain and signals sent by the irritated nerve.
- Relaxants and anti-depressants may be given in people, who experience anxiety or stress. Medications to manage post-traumatic stress disorder may be considered in those experiencing hemifacial spasm due to nerve injury or trauma.
Most of these medicines have side effects like dizziness, nausea, gastric disturbances, etc. These medicines that can provide relief from hemifacial spasm need to be taken with physician’s advice and any side effects must be discussed to find a solution.
Physical Therapy - Physical therapy for hemifacial spasm may be applied. It uses modalities to relax tense muscles, reduce discomfort and muscular twitching, which may be considered, as appropriate. Electrical nerve stimulation (TENS) and similar techniques that help to relax muscles and relieve irritated facial nerve may be considered.
Nutritional Therapy – Deficiency of certain vitamins and minerals may be related to the complaints of hemifacial spasm. In such cases, along with a healthy diet, nutritional supplements may be advised. Magnesium, calcium, iron or other minerals and vitamin B12, folic acid and B complex may help to manage hemifacial spasm in some cases. Vitamin and mineral supplements may be prescribed, as appropriate in such cases.
Botox Injections for Treating Hemifacial Spasm
Treatment of hemifacial spasm may also include Botox injections, in some persons. These are injections of Botulinum toxin, which are injected into the facial muscles, using a fine needle with an aim to weaken them. This toxin blocks the neurotransmitter, which is responsible for carrying signals through the nerve, which cause the muscle to move. Blocking the signal, prevents muscle contractions and offers relief in hemifacial spasm.
The dose, the number of injections and the muscles which need to be injected are decided by the physician. In most cases, Botox injections are repeated after few months, as prescribed by the physician. Some people may experience certain side effects like irritation, sensitivity of eyes, or temporary weakness of facial muscles.
Alternative Therapies for Treating Hemifacial Spasm
Use of complementary therapies that offer relaxation can be used to manage hemifacial spasm. Some people may find relief with acupressure, reflexology, aroma therapy or essential oils and meditation. Ayurveda, naturopathy and homeopathy too offer great remedies that can help to treat hemifacial spasm. The efficacy and tolerance of each person to any of these therapies is different and must be opted under the guidance of a specialist.
Surgical Treatment for Hemifacial Spasm
Hemifacial spasm in some people, may not respond to medical treatment or Botox injections. In such cases, surgery for treatment of hemifacial spasm may be considered. Some of the surgical options to treat hemifacial spasm include
Microvascular decompression surgery (MVD) to Treat Hemifacial Spasm
This surgical procedure is done when the facial nerve is compressed by vascular structure or an artery. Surgery is done by exposing the facial nerve, so that the pressure on the nerve, caused by the artery can be released. This helps to relieve facial nerve compression and symptoms of hemifacial spasm. Like any other surgery this option too has certain risks and they should be discussed, before taking a decision.
Lifestyle Management for Hemifacial Spasm
Lifestyle management of hemifacial spasm may include use of other methods in addition to medical treatment.
Counselling - Counselling and psychotherapy can help the body and mind to relax. Stress management, yoga and relaxation techniques, may also be helpful to complement the treatment of hemifacial spasm. Regular exercises can help to keep the body fit and stress releasing hormones can help to keep the mind calm. Deep breathing exercises can help to relax the mind, improve blood circulation in the body and relieve pain or distress, associated with symptoms of hemifacial spasm.
Diet - A diet rich in whole grains, healthy fats, fresh fruits, vegetables and plenty of water can be helpful in managing hemifacial spasm. Drink plenty to water and fluids to maintain electrolyte balance, provide lubrication to joints and keep muscles supple. Consuming foods rich in minerals like magnesium, calcium, potassium, which are commonly found in fruits, green vegetables, nuts, seeds and beans can be beneficial.
Massage - Gentle facial massage can help to relieve the stress in the facial muscles and relieve hemifacial spasm. Massage oil or face cream can be used on the fingers to make gentle circular movements on the face and the cheeks.
Following certain do’s and don’ts can help to maintain a healthy lifestyle that can aid the treatment of hemifacial spasm.
- Avoid intake of stimulants, caffeinated beverages, smoking or alcohol, as these can aggravate nerve irritation. It is better to avoid highly seasoned foods, heavy preservatives or high fatty foods. Healthy alternatives like milk, green tea, coconut water, fresh fruit and vegetable juices can be consumed instead.
- Avoid sitting late night, getting over stimulated or even overuse of electronic gadgets, as these too can irritate the nerve and aggravate symptoms of hemifacial spasm. Make sure you remain relaxed, get a good night’s sleep and feel refreshed on waking up. Setting up a schedule for work and relaxation can help.
Exercises for Hemifacial Spasm
Hemifacial spasm mainly affects the facial nerve and produces symptoms in the facial muscles. Involuntary facial muscle twitching or contractions are a result of improper nerve signals. In order to manage the symptoms of hemifacial spasm, gaining control of the facial muscles and strengthening the muscles is essential. Exercises for hemifacial spasm focus on strengthening facial muscles, improve muscle control, co-ordination and soothing the nerves.
Some exercises that can help to treat hemifacial spasm include
Facial Movements – Facial muscles are located all over the face and they help to make different facial movements. Exercises of facial movements are the most basic physical therapy to treat hemifacial spasm. The common movements of the face, like frowning, raising eyebrows, closing eyelids, smiling, holding the smile for few seconds, opening and closing the mouth, etc. can be performed slowly to improve the strength and coordination of the facial muscles. Whistling, blowing and sucking activities, holding objects in the mouth can help to strengthen the muscles around the lips.
Making Sounds – Another common exercise recommended in physical therapy for hemifacial spasm includes, making different sounds using the mouth. Saying out vowels loudly and slowly also helps.
Facial Yoga – Facial yoga is popularly performed for antiaging, but the main muscles strengthened are the facial muscles and can also help to treat hemifacial spasm.
- Closing the eyes tightly, holding for few seconds and releasing.
- Making an ‘O’ shape, while keeping the lips turned inwards to hide teeth. Further steps include smiling in the same ‘O’ shaped mouth posture and holding the smile for few seconds.
- Pressing one finger at the inner end and the other finger at the outer end of the eyebrow. Further steps include looking up in the same face posture and pressing with both fingers on both eyebrows at once.
- Keeping fingers of hands loose and patting the cheeks with the fingers to relax the facial muscles.