Overview of Hemifacial Spasm Treatment

Hemifacial spasm is a condition that is characterized by twitching of the muscles of the face. The spasms are a result of abnormal electrical signals in the facial nerve that result in twitching and spasming of the muscles of one side of the face that can cause abnormal facial expressions. Other symptoms include difficulty in vision (caused by twitching of the eye muscles), abnormal movements of the mouth, a ticking sound in the ear, and difficulty sleeping.

The most common cause of hemifacial spasm is compression of the facial nerve by a blood vessel. Other rare causes include a brain tumor that compresses the facial nerve, Bell’s palsy, and multiple sclerosis. In rare cases, a cause cannot be identified. Finding the reason for hemifacial spasm is important, because it will determine the best treatment strategy.

Numerous treatment options are available, each with their own pros and cons. Your neurosurgeon will be the best person to guide you through the best options for you, based on your symptoms, the cause of the spasms, and expectations.

The current treatment options for hemifacial spasm include medications, onabotulinum toxin A (Botox, Allergan Aesthetics, Irvine, CA) injections, and surgery.

Medical management of hemifacial spasm is usually the first step in treating this disorder. Your doctor will prescribe you with one or a few medications that will reduce the severity and frequency of the spasms. The following are the most commonly prescribed drugs.

• Carbamazepine: a medication commonly used for epilepsy. It works for hemifacial spasm by reducing the electrical signals transmitted through the facial nerve, which result in less twitching of the facial muscles. Some side effects that you may encounter are dryness of the mouth, dizziness, rash, and recurrent infection.
• Clonazepam: a drug used to treat anxiety and muscle spasms. A few side effects that you may face are drowsiness, dizziness, and nausea. It is important to note that clonazepam has potential for addiction, so you should take it only when and how it has been prescribed by your neurologist.
• Baclofen: a muscle relaxant that prevents muscle twitching and spasms. Side effects can include fatigue, constipation, and hypotension.
• Gabapentin: an antiepileptic drug commonly used for neuropathic pain. Common side effects include sleepiness and drowsiness; some rare side effects include suicidal thoughts and depression.

When you opt for medical management of hemifacial spasm, there are a few things you must keep in mind. If you are suffering or have suffered from depression or other psychiatric illness in the past, certain drugs might not be ideal for you. You must also let your neurologist know if you are pregnant. Certain medications are dangerous in women who are pregnant or breastfeeding. You should also let your doctor know about any other medical conditions you have, such as heart disease, kidney disease, or glaucoma. Telling your doctor about your allergies will help in deciding the best medicine for you. Based on any side effects you encounter, your doctor can adjust the dose of the medication or change the medication itself after assessing the risk/benefit ratio in your particular case.

Medical management of hemifacial spasm usually reduces the frequency and severity of the condition. However, many people do not find adequate relief of symptoms and develop side effects such as fatigue, slow thinking, and memory problems. In these situations, you may need to use another treatment.

Botox is a botulinum toxin (type A) that is used as a muscle-paralyzing agent to prevent hemifacial spasm. Botox is injected into the facial muscles, which results in those muscles not contracting despite electrical signals from the facial nerve. This reduces the twitching and spasms in the face. The procedure usually involves multiple injections into the affected muscles. The treatment is usually offered to those who do not feel that their symptoms are better after medical management.

The advantage of Botox injections is their effective paralysis of the facial muscles. Most patients symptoms improve after the injections. However, injections must be repeated every 3 to 6 months, because their effect will fade over time. The dosage of Botox and the muscles to be treated are determined according to your specific condition. Immediately after an injection, you could develop drooping of the eyelid, double vision, or difficulty speaking, each of which will usually subside after a few days. Long-term side effects can include facial asymmetry and resultant undesirable cosmetic changes in the face.

Long-term Botox injections may lead to permanent undesirable cosmetic changes and therefore definitive surgical intervention should be considered by visiting a neurosurgeon with significant experience in performing the surgery. Many patients find the gradual return of spams near the end of each Botox cycle problematic and seek more lasting therapy.

Surgery for hemifacial spasm is offered to those who do not find symptomatic relief from either medications or Botox injections and desire a definitive and durable solution.

Surgery is particularly useful for those who are found to have a blood vessel compressing their facial nerve on an MRI. Unlike medications and Botox injections, surgery provides relief by dealing with the cause of the spasms. Microvascular decompression is the most commonly performed surgery.

Microvascular decompression involves making an incision at the back of the head, behind the ear, so that the neurosurgeon can access the facial nerve by creating a small opening in the skull. The blood vessel compressing the facial nerve will be gently mobilized, and a cushion sponge is placed between the two of them, which should prevent further compression and irritation of the facial nerve. You will be asked to stay in the hospital for a few days after the surgery.

A large majority of patients’ spasms disappear within a few days after surgery, but a small minority require other treatments. Very few patients develop complications such as facial weakness, hearing loss, difficulty swallowing, hoarseness of voice, and impaired coordination. Some other general possible complications are bleeding, infection, and cerebrospinal fluid leak from the surgical site. If performed by experienced neurosurgeons, the surgical risks are small.

Another surgical option which is rarely performed is radiofrequency thermal coagulation (RFTC). RFTC is a relatively less invasive surgery than microvascular decompression. It is offered to those who do not have a blood vessel or tumor compressing the facial nerve. It is also offered to those who are not healthy enough to undergo general anesthesia, which is required for microvascular decompression. Only local anesthesia is used for RFTC. A probe is introduced into the skull through highly precise instruments. The probe just touches the facial nerve, which is then heated to cause damage to some of the nerve fibers in the facial nerve. This damage to the facial nerve causes a reduction in the frequency and strength of the signals passing through it. Although most patients report an improvement in symptoms, RFTC is not as effective as microvascular decompression. The most common side effect is facial paralysis, which is usually temporary.

Surgery might also be required if the cause of the hemifacial spasm symptoms is a brain tumor or arteriovenous malformation. You should discuss with your neurosurgeon whether surgery is the right option for you.

Stereotactic radiosurgery (SRS) directs radiation beams to a desired part of the brain with a high level of accuracy and precision. SRS works by causing partial damage to the facial nerve, thereby reducing the frequency and severity of facial twitching. SRS is a noninvasive method of treatment, meaning that you will not have any visible incisions or scars. You will be asked to lie down in a radiotherapy bunker while the machine targets the facial nerve with precise beams of radiation. Radiosurgery is rarely performed for hemifacial spasm due to the great results from microvascular decompression.

The commonly used SRS systems are Gamma Knife, linear accelerator–based systems such as CyberKnife, and proton beam therapy. Each system has different levels of accuracy, precision, availability, and cost. Your neurosurgeon can help you decide the best system for you.

In general, SRS treatment requires only one session, and you should be able to go home by the end of the day. Once you arrive in the morning, a frame will be placed over your head. Some systems require you to wear a custom-made mask. Once the head frame has been placed, you will undergo an MRI scan to determine the exact coordinates of the facial nerve and the precise location to be targeted. Afterward, you will be asked to lie down in the radiotherapy bunker, and the treatment will begin. The procedure usually takes little more than an hour. After the treatment has been completed, the head frame is removed, and you will be discharged.

Some side effects of SRS are pain at the sites where the head frame was attached, headache, facial weakness, facial pain, and hearing loss. Most of these side effects are temporary.

The SRS is a good treatment option for people who are not healthy enough for general anesthesia. Apart from the side effects, some of the disadvantages of SRS are that the hemifacial spasm might take longer to subside, and the long-term relief of symptoms is not as effective as surgery. Also, SRS systems are available only at highly specialized centers and might be further from your home. You will also need to consider the costs of such sophisticated treatment modalities.

Hemifacial spasm is known to worsen with stress and fatigue, and in turn, the spasms increase stress. This vicious cycle can be frustrating. It is therefore important to reduce overall stress and anxiety in a holistic manner. Getting enough sleep can be the first step in this direction. Relaxation techniques such as yoga and meditation can be of benefit.

There is some evidence to suggest that magnesium can be beneficial for patients with hemifacial spasm. A study published in the journal Headache found that magnesium supplementation was effective in reducing the frequency and severity of the spasms in some participants.  However, more research is needed to fully understand the relationship between magnesium and hemifacial spasm. Be sure to consult with a healthcare professional before starting any new supplements or treatments.

Eating a healthy diet can help prevent vitamin and mineral deficiencies. Gentle massaging and facial exercises have also been seen to help. Some patients say they have felt better after physiotherapy or acupuncture. You should consult your doctor about any nonmedical options you might want to pursue.

• Hemifacial spasm can be a frustrating condition, but multiple treatment options are available.
• Medication can reduce the severity of symptoms, but a lot of people do not feel significantly better.
• Botox injections provide significant symptom relief but repeat treatments are required every 3 to 6 months.
• Surgery is the definitive treatment option that most effectively deals with the root cause of the problem; microvascular decompression is the most commonly performed surgery.

• American Association of Neuromuscular & Electrodiagnostic Medicine
• National Institute of Neurological Disorders and Stroke