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I have leg muscles twitching when I lie down to sleep, both for naps & bedtime, it has gradually gotten worse over the last year. My upper thigh muscles were twitching first the left leg fulled by the right leg. The twitching seemed to always come in volleys of three. I did not know that it was MG/pyridostigmine related until I read about it in this form. My neurologist had me reduce my dosage from 90 mg 3 times a day to 60 mg three times a day . The intensity and frequency of twitching was reduced but was still there. I went ahead and tapered the doses of pyridostigmine down to zero. The twitching reduced in intensity & frequency with each drop in dosage but never went away completely. Pyridostigmine never went completely away even after 5 days at zero dosage. My impression is that pyridostigmine does not cause the twitching, but does it dose make it worse. I am back to taking 60 mg three times a day, but I am not sure why.