Objectives Blepharospasm (BSP) is a movement disorder characterized by bilateral and synchronous spasms of the orbicularis oculi (OO) muscles, but also by other manifestations, including an increased blink rate. Moreover, OO muscle spasms may be brief or sustained. We investigated whether the different types of spasms characterize subpopulations of patients with different natural history and disease progression and whether increased blinking should be considered a prodrome of blepharospam. Methods in patients with BSP we used a cluster analysis to identify homogeneous groups of cases. We have also investigated blink reflex recovery cycle, one of the most consistent neurophysiological abnormalities in BSP. Finally, in a longitudinal study, we have clinically and neurophysiologically tested a group of patients with increased blinking: upon enrolment and 5 years later. Results cluster analysis identified three groups of BSP patients that differed on the basis of the type of spasms and the disease severity. Blink reflex recovery cycle also differed across groups. The longitudinal investigation in patients with increased blinking showed that blink reflex recovery cycle, that was normal upon enrolment, became altered in the majority of patients at the follow-up assessment. Discussion and conclusions BSP patients may be classified in subtypes according to the types of OO spasms. Clinical heterogeneity reflects differences in blink reflex excitability. Increased blinking may precede blepharospasm and an abnormal blink reflex recovery cycle reflects the development of OO spasms. Significance heterogeneity of BSP reflects differences in the pathophysiological mechanisms which can be potentially relevant for clinical and therapeutic trials.