Facial myokymia as the presenting feature of multiple sclerosis

Clinical summary

A 23-year-old right-handed Caucasian woman presented with a 2-week history of continuous facial myokymia. This had begun in the left periorbital region, spreading to involve the entire left face, accompanied by left hemifacial spasms. It increased in intensity and subsequently spread to the right periorbital and perioral region, continuing during both when awake and asleep. She was otherwise well, taking no medications and with no significant family or travel history.

On examination, there were continuous high-frequency, low-amplitude facial twitching, consistent with continuous facial myokymia (see online supplemental videoonline supplemental video), which was more marked and appeared to be of higher frequency on the left side of the face than on the right. She had left hemifacial spasm, characterised by upward distortion of the left side of her mouth (activation of zygomaticus major) and a left pseudoptosis (activation of orbicularis oculi) (figure 1). Examination of the cranial nerves,…

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