Periorbital pain is unusual in patients with blepharospasms. We report a patient with hemifacial spasms who presented with severe ipsilateral periorbital aching pain. After treatment with botulinum toxin type A, the left hemifacial spasms and left periorbital pain improved temporarily. Microvascular decompression surgery was then performed for the facial spasms. The patient's left hemifacial spasms disappeared immediately after the operation, and his left periorbital pain was also totally resolved.