What causes persistent muscle twitching in a 43-year-old male with mild anxiety and controlled hypertension??

Hello doctor,

I am a 43-year-old male with a history of mild anxiety and controlled hypertension. I have been experiencing persistent muscle twitching for the past three months, and it has become mentally exhausting. I have given a detailed account of my symptoms.

Three months ago, I noticed a random twitch in my right bicep, which occurred approximately 10 to 12 times a minute for about a week. The following week, the twitching stopped in my bicep, but I started experiencing twitching in my left thigh, again at a frequency of 10 to 12 times per minute. Over the next two weeks, the twitching seemed to jump around to various muscle groups, including my chin, eyelid, and gluteal muscles. It would stop in one area and start in another. I have not noticed any muscle wasting or weakness during this time, and I have maintained my usual physical activities, including walking two miles a day and lifting the same weights as I did a year ago.

I consulted my primary care physician who conducted standard tests for twitching, including NCS and an EMG. All the laboratory results were normal including tests for B12, vitamin D, potassium, calcium, CBC, comprehensive metabolic panel, CK-MM, CRP, liver function, HIV, magnesium, and Lyme disease. The only abnormality was a positive ANA at a titer of 1:80 with a speckled pattern. By the end of the first month, the twitching had mostly localized in my left calf muscles, occurring at random locations within the muscles. The pattern remained consistent for about two weeks before shifting to my right calf muscles over the following month.

A more comprehensive NCS and EMG, which were reviewed by both a physiatrist and a Neurophysiology-trained MD, were found normal, with the exception of a minor carpal tunnel issue. It was recommended that I take daily magnesium (400mg), even though my magnesium levels were normal, and use magnesium lotion or oil on hot spots. They also suggested seeing a psychiatrist because my twitching seemed to worsen when I focused on it or experienced anxiety due to concerns about potential underlying conditions. I was prescribed Buspirone and Cozaar for daily use and Ativan for panic attacks, which initially helped reduce my symptoms.

Currently, about 75 % of the twitching is in my right foot (top, bottom, and sides), with the remaining 25% occurring in random locations. I still do not experience pain, muscle weakness, or wasting, and I can perform all activities as before. A friend who is a FNP performed a neuro assessment and found that all was normal, including cranial nerves, absence of Babinski and Hoffman signs, normal gait, and symmetrical muscle tone. But, hyperactive reflexes were noted at all stations. She suggested that the twitching is either my normal state or driven by anxiety and concluded that there was no muscle weakness or wasting.

I also occasionally feel an unusual sensation on my right outer calcaneus, as if I am stepping on something that pops. This sensation is limited to one spot and is similar to stepping on a single bubble wrap bubble. No weakness or atrophy is associated with it. My friend believes this is unrelated or has been present for a while, but I am only noticing it now due to hyper-focus on my symptoms. Just yesterday, twitching started in my left foot, which has intensified my worry. I have not experienced any mouth or tongue twitching.

Throughout this period, the twitching usually stops immediately with movement but often restarts in the same location when movement ceases. It is most noticeable at rest.

I maintain a daily exercise routine, take testosterone every two weeks, and consume 120 ml of water daily. Although I have a history of anxiety related to flying and confined spaces, it does not compare to the worry, concern, and desire to research my current symptoms.

Now, for my questions:

1. I would appreciate your thoughts on whether my symptoms could be indicative of something serious, related to anxiety, or benign fasciculation syndrome.
2. Do you recommend any additional tests for conditions like multiple sclerosis or amyotrophic lateral sclerosis?
3. Could the initial NCS and EMG have been conducted too early to detect potentially serious conditions, especially if the primary symptom is twitching?
4. While most sources suggest that three months without weakness or wasting is a positive sign, could the pattern of twitching and its movement to different locations indicate disease progression?

I am deeply grateful for your assistance and insights in this matter.

Thank you.