When to Worry About Eye Twitching

I recently saw Eileen, a 45-year-old female accountant, in my office who reported an aggravating “eye twitching.” Now this is a common, yet potentially annoying, medical problem. It may not be debilitating, but it’s sometimes enough to distract you from your tasks and drive you bonkers.

Eileen tells me that she’s had intermittent and multiple bouts of seemingly non-stop eye twitching in her eyelid almost daily for one month, with each episode a few minutes long. It’s enough to interfere with her work. She gets through the day but gets distracted by the twitching.  It’s tax season, and she needs to tackle this quickly so that she can be more efficient at her job.


The reason she came in today is because she’s never experienced this before and is concerned that she may have a brain tumor after googling her symptoms online. After reassuring Eileen that eye twitching due to a brain tumor is quite uncommon, I go on to take her history.

Let’s walk through a visit with Eileen to find out what caused her twitching and how she treated it.

Patient History

Her past medical history: Looking through her chart in the electronic medical records, I can see that Eileen is rather healthy, suffers only from hypertension for which she keeps under good control with a diuretic that she’s been taking for more than five years.

Her history of present illness:  Upon further questioning, Eileen reports that the twitching is only in her left eye and that only the lower eyelid is involved (the most common location). She does wear glasses, but only for reading. Her last eye exam was almost a year ago. But other than that, Eileen and her eyes are quite healthy—no prior surgeries or issues in the past.

Now that I have the details of her current symptoms, I need to make more targeted and specific questions that we haven’t answered just yet.

The Differential Diagnoses

When taking the “history” portion of the visit, doctors are trained to go through a potential list of possible causes of a symptom, termed the “differential diagnosis.”


In fact, this is a popular way to quiz medical students and resident physicians in order to see how well they can problem solve. This is known as “pimping,” where supervising physicians and those up higher in the hierarchy test those in medical training. Like I’ve mentioned before, medical training is not unlike the military.

For eye twitching, a not terribly uncommon medical complaint, it’s important to think of the differential diagnosis. Thinking through my potential list of causes, I start to ask questions to address each possibility:

Eye strain:  Prolonged computer use can cause eye strain and fatigue. Muscles surrounding the eye can get fatigued and then twitch. Eileen does work on the computer for the majority of her day at work as an accountant.

Caffeine and Alcohol:  Both are diuretics, which mean they cause more excretion of fluids through urine. And this dehydration can cause muscle cramps and twitching. Eileen typically drinks one cup of coffee every morning, but lately admits to having consumed an extra cup in the afternoons during tax season.

Allergies: Inflammation of the eye can also put strain on the eyelids and make them twitch. Eileen doesn’t have any significant allergy symptoms.

Dry eyes: Dry eyes cause irritation of the eyes and render it more prone to problems. Eileen is unsure if she suffers from dry eyes.

Eye injuries: Contusions or any injuries to the eye can also cause twitching. No injuries for Eileen.

Eye Irritation: Irritation and inflammation of the eye can cause eye twitching. Eileen has not been exposed to any air pollution or chemicals, has not recently suffered from pink eye, and no history of blepharitis (inflammation of the eyelids).


Lack of sleep: Insomnia causes fatigue. And fatigue of the eyes can also cause it to twitch. Fortunately, Eileen has always been a good sleeper, maintaining a routine bedtime schedule and having excellent sleep hygiene.

Medications: Anti-seizure medications and anti-psychotics can cause eye twitching. Diuretics used to treat high blood pressure can contribute as well.  But Eileen has been on the same diuretic for her high blood pressure for over five years without any problems until now.

Unknown etiology: Many types of eyelid twitching occur without an identifiable cause.

Other more serious causes of eye twitching due to problems with a nerve or the brain are rare, as I mentioned previously. And they often include other abnormal symptoms besides just eye twitching. These include the following medical conditions:

  • Benign Essential Blepherospasm (a benign but chronic eyelid twitching disorder)
  • Tourette’s Syndrome
  • Multiple Sclerosis
  • Oculomotor Nerve Palsy (a problem with the oculomotor nerve)
  • Parkinson’s Disease

Physical Exam

I see that my wonderful nurse has already completed a screening vision exam prior to my visit with her, and as expected Eileen has normal vision. I then exam Eileen’s eyes with a special scope to visualize the back of the eye, in addition to examining her eye range of motion and peripheral vision.  I also perform a complete neurologic exam (including other parts of the body).  And her entire examination appears to be completely normal, as most people with eye twitching. I did get to see her left lower eyelid twitch a few times during our visit, however.

Treatment of Eye Twitching

Given that her exam was completely normal, and that her history indicates more benign causes of eye twitching, I ask Eileen to do the following for the next few weeks and then to return in 3-4 weeks to re-asses:

  • Drink no more than one cup of coffee a day (as in her baseline) or stop it altogether
  • Stop drinking Alcohol if she’s drinking any
  • Drink plenty of fluids (drink to thirst, no need to overdo it)
  • Make sure to wear her glasses at work for near vision
  • Give her eyes a break every 20 minutes computer use
  • Use artificial tears several times a day, especially while at work
  • Continue to get good sleep each night

Diagnosis

When I saw Eileen back in the office five weeks later, she tells me that she is much improved. Like many medical conditions, her eye twitching was actually “multifactorial” (meaning due to several factors, not just one). It may have been improved by any of the following factors:


  • She’s taking a diuretic for her high blood pressure (although no need to stop it at this junction)
  • Drinking more caffeine than usual
  • Eye strain due to increased computer use because of tax season
  • Dry eyes (the weather in Southern California—just think desert)

So as you can see, each risk factor alone may not cause any symptoms.  But compound it all together, and voila!, you have a problem.

Most eyelid twitching is not serious and self-resolves. It is also typically only on one side, involves the lower eyelid (but not always), and can last for weeks to months intermittently.

When Should You Worry About Eye Twitching

You should see your doctor if:

  • The twitching persists for weeks despite some minor changes discussed above
  • The twitching worsens through time
  • There’s associated light sensitivity
  • If there is twitching of other parts of the face
  • It’s severe enough to cause the eyes to shut close with each twitch
  • There’s difficulty opening the eyes or there is a droopy eyelid
  • There are any other neurological symptoms (numbness, motor deficits, speech deficits, visual field deficits, etc)
  • There’s blurry vision or any problems with the vision
  • There is associated redness, swelling, or abnormal discharge from the eye

Another mystery diagnosis … solved.


Please note that all content here is strictly for informational purposes only.  This content does not substitute any medical advice, and does not replace any medical judgment or reasoning by your own personal health provider.  Please always seek a licensed physician in your area regarding all health related questions and issues.

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