Eyelid twitching: causes, how long it lasts and when to see a GP

The NHS says most people get twitches from time to time and that they are often linked to stress and anxiety, tiredness and exhaustion, drinking caffeine or alcohol, and some medicines (it advises checking the side effects on the packet or leaflet). It says twitches in the eyes or legs are particularly common, and you may also have tingling or cramps in the same area.

A Moorfields consultant ophthalmic surgeon lists typical causes of eyelid twitching as being tired or short of sleep, having dry eyes, having too much caffeine, using nicotine and stress, and says that if people address these, the twitching will often stop.

For blepharospasm, Cambridge University Hospitals says the exact cause is unknown but is often attributed to a loss of control of the natural blink reflex. Bright light, stress and fatigue can trigger episodes, and the pattern may vary through the day. For hemifacial spasm, the same leaflet explains that some people are found to have a blood vessel close to the facial nerve and intermittently touching it, and that after facial paralysis from another cause, such as Bell's palsy, the facial nerve can recover in an abnormal way and become over-active.

The Borders referral toolkit asks clinicians about medicines that might cause electrolyte imbalance or muscle symptoms, giving diuretics as an example. If you take regular medicines and have started to twitch, tell the GP rather than stopping anything yourself, as the NHS also advises.

The NHS says a twitch may come and go, but will normally stop in a few days or weeks, and that there is not usually any treatment for it. It advises seeing a GP if a twitch lasts more than 2 weeks.

Cambridge University Hospitals says an episode of blepharospasm often lasts only a few minutes, but in severe cases it can last much longer and make everyday tasks difficult because the eyes cannot be kept open consistently. Blepharospasm that causes problems may be treated with botulinum toxin injections, which wear off over 8 to 12 weeks, so repeat treatment is needed.

People use "eyelid twitching" for several different experiences. The commonest is a small, repeated flicker in one eyelid, often the lower lid, that you may feel more than anyone else can see. Clinicians call this myokymia: painless, repetitive twitching of muscle fibres. An NHS Borders referral toolkit written for clinicians notes that it is commonly seen around the eye and is nearly always benign.

A twitch of this kind is not a disease of the eye itself. It comes from the small muscle that closes the eyelid, and it tends to come and go over days or weeks without leaving any mark. Because it is so visible to the person who has it, it can feel far more significant than it is.

Two other patterns are worth knowing about because they behave differently. Blepharospasm involves both eyes closing or blinking repeatedly because the muscle that closes the lids is overactive. Hemifacial spasm affects one side of the face, with the eye blinking and the corner of the mouth pulling upwards. They are discussed below, because the right response depends on telling them apart from simple myokymia.

The descriptions below draw on the NHS Borders toolkit and on the patient information leaflet from Cambridge University Hospitals. They are a guide to what clinicians look for, not a way of diagnosing yourself.

The NHS says twitches are very rarely a sign of anything serious and often go away on their own. It says to see a GP if a twitch lasts more than 2 weeks. Moorfields says that if a twitch does not stop, becomes constant, spreads to other parts of the face, or comes with other symptoms such as pain, you should consult your GP, because this is sometimes a sign of other conditions that may need to be investigated.

• You have a twitch for more than 2 weeks, or it keeps coming back and bothers you (NHS).

• You have a twitch in more than 1 place (NHS), or it spreads to the cheek or corner of the mouth.

• The affected area feels weak or stiff (NHS), or you notice a drooping lid, numbness or changes in vision.

• Both eyes are blinking or closing, or the lids close so that it is hard to see (Cambridge University Hospitals).

• You think a prescribed medicine might be causing it (NHS). Do not stop it without medical advice.

• Pain comes along with the twitching (Moorfields).

The NHS says that if a twitch does not go away, your GP may check for causes like stress or a medicine you are taking, ask you to come back if the twitch has not stopped in a few weeks, or refer you to a neurologist for tests to look for conditions that can cause a twitch. It lists benign fasciculation syndrome, dystonia and motor neurone disease as possible causes of a twitch that does not go away or happens with other symptoms, and says most twitches are not caused by a medical condition.

The NHS Borders toolkit for clinicians suggests that a GP asks whether there is any weakness, whether there is a family history, whether medicines might be involved, and whether the problem happens only at night. The tests it lists for primary care are a basic biochemical screen including urea and electrolytes, calcium and thyroid function, plus a creatine kinase level. For persistent facial spasm, a GP may refer to an eye clinic or neurology.

For simple myokymia the approach is explanation, reassurance and time. Rest, avoiding things that clearly trigger episodes for you, and treating any anxiety that is feeding the problem are the practical steps. The toolkit stresses that repeated reassurance-seeking can keep health anxiety going, so one clear explanation followed by getting on with normal life is usually more helpful.

For blepharospasm and hemifacial spasm that cause problems, the toolkit lists conservative management or botulinum toxin. Cambridge University Hospitals explains that the toxin temporarily stops nerves releasing the chemical signal acetylcholine, so the muscles that close the eyes relax. Small doses are injected just under the skin at two to six sites around the eyelids, with no anaesthetic needed, and the procedure takes about 5 to 10 minutes.

The injections start to work after 24 to 72 hours, with maximum effect by 2 to 3 weeks, and the effect lasts 8 to 12 weeks. The leaflet says consistent relief can be achieved with about four to five injections a year. The first injections are given by an ophthalmologist, and later ones can be given by a trained ophthalmic nurse specialist.

Possible effects include bruising, drooping of the eyelids and occasionally double vision, which are temporary and can last two to three months. The leaflet advises not rubbing or pressing the injection sites afterwards, and says the treatment is not suitable if you are pregnant or trying for a baby. People taking blood-thinning medicines need to tell the clinic. Surgery is described as rarely required for genuine treatment failure.

The NHS suggests the following for a twitch. It says a twitch is usually harmless and that worrying can make it worse.

• Get plenty of rest and try to find ways to relax.

• Stretch and massage any muscles affected by cramps.

• Try not to worry about it.

• Avoid drinking lots of caffeine, such as tea and coffee, and lots of alcohol.

• Do not stop taking a prescribed medicine without getting medical advice, even if you think it could be causing your twitch.

• Moorfields adds that addressing dry eyes, nicotine use and lack of sleep will often stop the twitching.

Most isolated eyelid twitching settles without treatment and does not progress to anything else. Blepharospasm is a long-term condition for many people, but it is controllable: Cambridge University Hospitals says that the majority of people with eyelid spasm experience relief after injections.

The Dystonia Society is named in the leaflet as a source of further information about eyelid spasm, and many people find that talking to others with the condition helps with the practical side, such as managing bright light and planning appointments around the 8 to 12 week cycle.

On the NHS the first step is the GP, who may refer to an eye clinic, often an oculoplastic or neuro-ophthalmology service, or to neurology. Botulinum toxin for blepharospasm is delivered in outpatient clinics, with a repeat visit roughly every few months. Private eye specialists can offer the same assessment and injections, usually with shorter waits and a choice of clinician. Treatment is repeated on the same cycle in either sector, so it is worth asking who would carry out follow-up injections and how a problem between visits would be handled.