eMedicine Specialties > Neurology > Movement and Neurodegenerative Diseases
Torticollis: Treatment & Medication
Updated: Dec 10, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
A comprehensive approach to the medical care of torticollis includes several treatment goals.
- Dystonia-reducing medication trials
- In torticollis, the conventional dopamine agonists and antagonists are not effective (dopamine receptors D1=D2), as distinguished from the L-dopa–responsive dystonias (a set of familial generalized dystonias).
- Anticholinergics (eg, trihexyphenidyl, benztropine) may be slightly effective but less so than in generalized or torsion dystonias.
- Try unconventional dopamine agonists (dopamine receptors D2>D1, such as pramipexole or ropinerole) or antagonists with D2, D3, D4 blocking activity, such as olanzepine or risperidone.
- Try glutamate release inhibitors (eg, riluzole) or glutamate receptor blockers (eg, high-dose amantadine, lamotrigine, memantine).
- Botulinum toxin injection is the current popular treatment of choice.
- Selective medication choices
- Clonazepam, especially if blepharospasm is part of the syndrome
- Baclofen, especially if oromandibular dystonia is part of the syndrome
- Nonspecific medication choices
- Propranolol or primidone if prominent oscillatory components
- Nonsteroidal anti-inflammatory drugs (NSAIDs) for arthritic components
- Physical medicine options
- Patients may respond well to sensory feedback training.
- Muscle relaxation techniques may be tried.
- Cervical braces occasionally are made that reproduce the tactile advantage of a sensory trick, which controls movement and/or reduces dystonia.
Surgical Care
Surgical care has been tried as a last resort for patients whose symptoms are refractory to botulinum injections.
- Selective ramisectomy for cervical musculature (late delayed recurrence can be a problem)
- Deep brain stimulator implants in the globus pallidus to control contralateral dystonia
Activity
Certain motor activities or prolonged postural vocational requirements may exacerbate pain. An ergonomics evaluation in the workplace can be helpful. Changing or selecting positions can also be beneficial (ie, sitting to the left or the right of a speaker to avoid cervical strain).
Medication
The goals of pharmacotherapy are to reduce morbidity and prevent complications. Medication categories are as follows: (1) dystonia reducing (eg, trihexyphenidyl, pramipexole, glutamate release inhibitors and receptor blockers, botulinum toxin) and (2) selective adjunctive (eg, clonazepam for blepharospasm, baclofen for oromandibular dystonia, propranolol or primidone for prominent tremor).
Anticholinergics
These agents reduce dystonia.
Trihexyphenidyl (Artane, Trihexy)
Central cholinergic blockade often effective treatment strategy in dystonias in all categories, not just torticollis. Doses used in nontorticollis dystonias often much higher than those suggested here. Anticholinergics should be tried initially and may be more effective in children than in adults. Children tend to tolerate much higher doses than adults.
Adult
6-10 mg PO in divided doses
Pediatric
Not established but may be as high as 40-60 mg in some cases when tolerated.
Amantadine may increase anticholinergic adverse effects that disappear when dose reduced; may decrease serum concentration of haloperidol, resulting in worsening of schizophrenic symptoms; may reduce pharmacologic/therapeutic actions of phenothiazines
Documented hypersensitivity; glaucoma; peptic ulcers; pyloric or duodenal obstruction; stenosing prostatic hypertrophy or bladder neck obstruction; achalasia; toxic megacolon
Pregnancy
A - Fetal risk not revealed in controlled studies in humans
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Dose adjustment may be required in elderly patients; caution in tachycardia, cardiac hypotension, prostatic hypertrophy, arrhythmias, hypertension, any tendency toward urinary retention, liver or kidney disorders, or obstructive disease of GI or GU tract; if dry mouth severe and impairs swallowing or speaking, or if loss of appetite and weight occurs, reduce dosage or temporarily discontinue medication
Dopamine agonist
Agents with high potency at the D2 receptor, relative to lower potency at the D1 receptor, can be used to enhance activity in the indirect pallidal outflow pathway (see Media file 1). This is especially useful in treating the cervical dystonias.
Pramipexole hydrochloride (Mirapex)
Especially appropriate because its D2 specificity fits SPECT and PET evidence of D2 underactivity in indirect pallidal outflow pathway. In addition, antidepressant properties are most appropriate to this group of patients and stem from pramipexole's additional specificity for D3 receptors. Because of tedium of regular painful injections required in botulinum toxin use, try pramipexole before toxin.
Adult
Preferred oral loading schedule: 0.125 mg PO tid for week 1; 0.25 mg PO tid for week 2; 0.5 mg for week 3; 0.25-mg increments tid in subsequent weeks until minimum effective dose achieved
Pediatric
Not established
Cimetidine may increase toxicity; may increase levodopa levels
Documented hypersensitivity; paroxysmal sleep reactions; refractory visual hallucinations unresponsive to dose reduction; symptomatic hypotension
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Withdrawal emergent neuroleptic malignant syndrome has been reported with abrupt discontinuation; fibrotic complications of long-term use of ergoloid drugs has been reported
Ropinirole hydrochloride (Requip)
Nonergot dopamine agonist that has high relative in vitro specificity and full intrinsic activity at D2 subfamily of dopamine receptors, binding with higher affinity to D3 than to D2 or D4 receptor subtypes. Has moderate affinity for opioid receptors. Metabolites have negligible affinity for dopamine D1, 5-HT1, 5-HT2, benzodiazepine, GABA, muscarinic, alpha1-, alpha2-, and beta-adrenoreceptors.
Precise mechanism of action as treatment for Parkinson disease unknown. However, possibly related to stimulation of dopamine receptors in striatum.
To avoid malignant hyperthermic complications when stopping the drug, discontinue gradually over 7-d period. Decrease frequency of administration from 3 tid to bid for 4 d. For the remaining 3 d, decrease frequency to once daily prior to complete withdrawal.
Serves as alternative to pramipexole if that drug has objectionable adverse effects. Dopamine receptor profile similar to that of pramipexole.
Adult
Ascending loading dose necessary, starting with 0.25 mg PO tid for week 1, followed by 0.25-mg increments PO tid per week until minimum effective dose achieved
Pediatric
Not established
None reported
Documented hypersensitivity; paroxysmal sleep reactions; refractory visual hallucinations unresponsive to dose reduction; symptomatic hypotension
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Withdrawal emergent malignant hyperthermia has been reported with abrupt discontinuation of similar dopamine agonists; fibrotic complications of long-term use of ergoloid drugs have been reported
Glutamate release inhibitors
Glutamate release inhibition and glutamate receptor blockade are alternatives to potentiating D2 receptors in the indirect pallidal outflow pathway by reducing the glutamate-related excitatory circuit in this outflow pathway (see Media file 1).
Riluzole (Rilutek)
Appears to block glutamatergic neurotransmission in CNS through indirect mechanisms. May inactivate voltage-dependent sodium channels. May also activate guanosine triphosphate-binding signal transduction proteins (G-proteins), which may cause inhibition of glutamate release.
Has the least adverse effects of the 3 drugs mentioned for glutamate release inhibition, but expense is prohibitive unless insurance carrier has a low copay. Because riluzole is classified as an Orphan Drug, the carrier is required to make payment by law (Federal Orphan Drug Act). Amantadine must be dosed above a threshold amount (usually 300 mg) to provide release inhibition above and beyond dopamine receptor agonism. Lamotrigine is an acceptable alternative, but effective dosing is not as clear and ranges from 25-100 mg tid. Memantine can also be tried as 10 mg bid.
Nevertheless, if riluzole is not covered by the insurance carrier, can try amantadine, lamotrigine, or possibly memantine.
Adult
50 mg PO bid
Pediatric
Not established
When used concurrently, caffeine, theophylline, amitriptyline and quinolones may decrease rate of elimination of riluzole, increasing toxicity; rifampin and omeprazole may decrease blood levels by increasing rate of elimination
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in abnormal liver function; monitor liver enzymes closely
Amantadine (Symmetrel)
Inhibits N-methyl-D-aspartic acid (NMDA) receptor-mediated stimulation of acetylcholine release in rat striatum. May enhance dopamine release, inhibit dopamine reuptake, stimulate postsynaptic dopamine receptors, or enhance dopamine receptor sensitivity. Glutamate receptor inhibition occurs at high doses only. Use only at 100 mg PO tid (lower doses or frequencies only provide dopamine agonism).
Adult
100 mg PO tid
Pediatric
Not established
Drugs with anticholinergic or CNS stimulant activity increase amantadine toxicity; the concurrent administration of hydrochlorothiazide plus triamterene with amantadine may increase plasma concentrations of amantadine
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in liver disease, uncontrolled psychosis, eczematoid dermatitis, seizures, and current use of CNS stimulant drugs; reduce dose in renal disease when treating Parkinson disease; do not discontinue this medication abruptly; stop use in mental changes, such as visual hallucinations, inattention, or night terrors; blotchy skin (ie, livedo reticularis) may occasionally occur (may be cosmetically objectionable in some patients and may lead to lower leg swelling if severe; in such cases, rimantadine at comparable doses can eliminate this problem)
Memantine (Namenda, Axura)
N-methyl-D-aspartate (NMDA) antagonist.
Adult
5 mg PO qd initially; gradually titrate to a 10-mg bid target dose (allow at least 1 wk between each dosage increase)
Pediatric
Not indicated
Coadministration with drugs causing alkaline urine (eg, sodium bicarbonate, carbonic anhydrase inhibitors) may decrease clearance by 80%, thus accumulation and toxicity may occur; coadministration with other NMDA antagonists (eg, amantadine, ketamine, dextromethorphan) may increase toxicity risk; concurrent use with other drugs renally eliminated via tubular secretion (eg, hydrochlorothiazide, triamterene, cimetidine, ranitidine, quinidine, nicotine) may alter plasma levels of either drug
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Common adverse effects include dizziness (7%), headache (6%), and constipation (5%); predominantly excreted renally, no data support use with severe renal impairment
Lamotrigine (Lamictal)
Blocks glutamate receptors and inhibits voltage-sensitive sodium channels, leading to stabilization of neuronal membrane. Back-up alternative to amantadine.
Adult
25-100 mg PO tid
Pediatric
Not established
Acetaminophen increases renal clearance of medication, decreasing effects; similarly, phenobarbital and phenytoin increase lamotrigine metabolism, causing a decrease in lamotrigine levels; administration of valproic acid with lamotrigine increases half-life; succinimide anticonvulsants (eg, methsuximide, phensuximide) decrease lamotrigine levels
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in impaired renal or hepatic function
Adrenergic beta-blockers
These agents offer antitremor action when overt tremor complicates torticollis.
Propranolol (Inderal, Betachron E-R)
Often first choice for tremor control in essential tremor and can be used as adjunctive medical therapy when tremor complicates torticollis.
Adult
Long-acting, controlled release: 80-160 mg PO qd
Pediatric
Not established
Recovery of blood glucose may be markedly delayed, making diabetic control with insulin difficult; catecholamine-depleting drugs can cause hypotensive crises; calcium channel blockers can cause extreme myocardial contractility; alcohol and aluminum hydroxide reduce absorption; phenytoin, phenobarbitone, and rifampin accelerate clearance, whereas cimetidine decreases clearance; decreases theophylline clearance
Documented hypersensitivity; bronchial asthma; cardiogenic shock; overt heart failure; heart block greater than first degree
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Recovery of blood glucose delayed when using insulin; abrupt withdrawal can precipitate angina; can lower intraocular pressure and yield false-negative readings for glaucoma tests
Anticonvulsants
Primidone is used in low doses for antitremor effect.
Primidone (Mysoline)
Low-dose form is traditional second choice for treatment of essential tremor. Also possibly effective as adjunct in treatment of torticollis with prominent tremor.
Adult
50 mg PO bid/tid
Pediatric
Not established
May decrease serum concentrations of ethosuximide, griseofulvin, valproic acid; phenytoin may decrease serum levels; methylphenidate may increase toxicity of valproic acid
Documented hypersensitivity; porphyria
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in renal or hepatic impairment; abrupt discontinuation of medication may precipitate status epilepticus when seizure threshold low; caution in pulmonary insufficiency
Benztropine (Cogentin)
By blocking striatal cholinergic receptors, may help balance cholinergic and dopaminergic activity in striatum. Can be used as alternative to trihexyphenidyl.
Adult
4-15 mg PO in divided doses
Pediatric
Not established
Decreases effects of levodopa; increases effects of narcotic analgesics, phenothiazines, quinidine, tricyclic antidepressants, and anticholinergics
Documented hypersensitivity; angle-closure glaucoma; stenosing peptic ulcers; prostatic hypertrophy or bladder neck obstruction; myasthenia gravis; pyloric or duodenal obstruction; achalasia (megaesophagus); megacolon
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
May exacerbate hypertension, tachycardia, cardiac arrhythmias, liver or kidney disorders, hypotension, prostatic hypertrophy, urinary retention, and obstructive disease of GI/GU tract; in extrapyramidal reactions resulting from phenothiazine treatment in psychiatric patients, toxic psychosis may occur
Nonsteroidal anti-inflammatory agents
These agents have analgesic, anti-inflammatory, and antipyretic activities. Their mechanism of action is not known, but they may inhibit cyclooxygenase activity and prostaglandin synthesis. Other possible mechanisms may include inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell-membrane functions.
Aspirin (Anacin, Bayer Aspirin, Ascriptin)
Treats mild to moderately severe pain. Inhibits prostaglandin synthesis, which prevents formation of platelet-aggregating thromboxane A2.
Adult
325-650 mg EC PO tid
Pediatric
Not established
Antacids and urinary alkalinizers may decrease effects; corticosteroids decrease serum levels; anticoagulants may cause additive hypoprothrombinemic effects and increase bleeding time; may antagonize uricosuric effects of probenecid and increase toxicity of phenytoin and valproic acid; doses > 2 g/d may potentiate glucose-lowering effect of sulfonylurea drugs
Documented hypersensitivity; liver damage; hypoprothrombinemia; vitamin K deficiency; bleeding disorders; asthma
Because of association with Reye syndrome, do not use in children ( <16 y) with flu
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
May cause transient decrease in renal function and aggravate chronic kidney disease; avoid use in patients with severe anemia, with history of blood coagulation defects, or taking anticoagulants
Ibuprofen (Motrin, Ibuprin)
DOC for patients with mild to moderately severe pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Adult
400-800 mg PO tid
Pediatric
Not established
Aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity; may decrease effects of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; anticoagulants may increase PT; instruct patients to watch for signs of bleeding; may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in congestive heart failure, hypertension, or decreased renal and hepatic function; caution in coagulation abnormalities or during anticoagulant therapy
Neuromuscular blockers
Paralysis of dystonic muscles by direct injection is used to reduce pain and abnormal posture.
Botulinum toxin type A (BOTOX®); botulinum toxin types B-F (BTX types B-F)
Although considered treatment of choice because of degree of effectiveness, the duration of paralysis is limited to a few months, multiple sites must be injected, and EMG-guided injections in neuromuscular junction are tedious and painful. On this basis, early oral medication trials with other drugs are desirable.
Alternatives to botulinum toxin type A (especially B and F) can be used if a patient develops resistance to type A by producing type A antibodies.
Must be reconstituted from vacuum-dried toxin into 0.9% sterile saline without preservative according to manufacturer's instructions to provide injection volume of 0.1 mL; must be used within 4 h of storage in refrigerator at 2-8°C. Preconstituted dry powder must be stored in a freezer at <5°C.
Adult
100-300 U IM; repeat injections q4-6mo (latency of improvement 1 wk, duration of maximum improvement 3-4 mo)
Pediatric
Not established
Aminoglycosides or drugs that interfere with neuromuscular transmission may potentiate effects
Documented hypersensitivity; antibodies to botulinum toxin types
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Anaphylactic reaction may occur (botulinum toxin is a biologic product); do not exceed recommended doses and frequencies of administration; some patients develop antibodies to botulinum toxin type A, which block effectiveness (in such patients, make arrangements for an antigenically different type [especially types B and F])
Consider individual sensitivities to dose injection weakness, especially dysphagia in serial injections, which typically last 2 wk; dysphagia may occur transiently from injections of sternocleidomastoid on one or both sides
Antispastic/gamma-aminobutyric acid inhibitors
As an inhibitor of the neurotransmitter GABA, baclofen can be used as an adjunctive medication when torticollis is complicated by oromandibular dystonia.
Baclofen (Lioresal)
Can be used to supplement other medications used to treat torticollis when oromandibular dystonia present.
Adult
40-120 mg PO divided tid/qid
Pediatric
Not established
Opiate analgesics, benzodiazepines, alcohol, tricyclic antidepressants, guanabenz, MAOIs, clindamycin, and hypertensive agents may increase effects
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in history of autonomic dysreflexia and when spasticity used to obtain increased function; autonomic dysreflexia can result from withdrawal of this medication
Benzodiazepines
These agents provide adjunctive treatment for patients with blepharospasm.
Clonazepam (Klonopin)
Preferred benzodiazepine for movement disorders. Can be used alone or to supplement other medications used to treat torticollis complicated by blepharospasm.
Adult
1-12 mg PO divided bid/tid
Pediatric
Not established
Phenytoin and barbiturates may reduce effects; CNS depressants increase toxicity
Documented hypersensitivity; hepatic disease; acute narrow-angle glaucoma (not contraindicated in open-angle glaucoma with use of appropriate treatment)
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Reduce doses in renal failure to avoid toxicity; abrupt discontinuation may cause withdrawal symptoms with anxiety, dizziness, and possibly seizures; hypersalivation has been reported
Antipsychotic agents
These agents are useful in treating dystonia associated with torticollis.
Olanzepine (Zyprexa, Zyprexa Zydis)
May inhibit serotonin, muscarinic, and dopamine effects. Exerts dopamine receptor blockade in both striatal (D2>D1 receptor blockade) and in nonstriatal sites (D3, D4).
Adult
5-10 mg PO qhs
Pediatric
Not established; 2.5-5 mg PO qd after achieving puberty is suggested
Fluvoxamine may increase effects of olanzapine; antihypertensives may increase risk of hypotension and orthostatic hypotension; levodopa, pergolide, bromocriptine, charcoal, carbamazepine, omeprazole, rifampin, and cigarette smoking may decrease the effects of olanzapine
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in narrow-angle glaucoma, cardiovascular disease, cerebrovascular disease, prostatic hypertrophy, seizure disorders, hypovolemia, and dehydration; hyperglycemia may occur and in some cases be extreme, resulting in ketoacidosis, hyperosmolar coma, or death; administration of more than one IM injection is associated with substantial orthostatic hypotension (33%), maintain patient in recumbent position and monitor blood pressure before repeating IM doses
Risperidone (Risperdal, Risperdal M-Tab, oral disintegrating tablet)
Atypical neuroleptic. Binds to dopamine D2-receptor with 20 times lower affinity than for 5-HT2-receptor affinity. Has both striatal blocking action (D1 0.5-1.0 mg PO qhs Not established; 0.25-0.5 mg PO qhs after achieving puberty is suggested Coadministration with carbamazepine may decrease effects; risperidone may inhibit effects of levodopa; clozapine may increase risperidone levels; oral solution not compatible with cola or tea Documented hypersensitivity C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus May cause extrapyramidal reactions, hypotension, tachycardia, and arrhythmias; hyperglycemia may occur and in some cases be extreme, resulting in ketoacidosis, hyperosmolar coma, or death; do not split or chew oral disintegrating tablets; lower dose and slower titration may be required in elderly or debilitated patients, those with severe renal or hepatic impairment, or individuals predisposed to hypotension; elderly patients with dementia-related psychosis treated with atypical antipsychotic drugs have increased risk of death compared to placeboAdult
Pediatric
Pregnancy
Precautions
More on Torticollis |
| Overview: Torticollis |
| Differential Diagnoses & Workup: Torticollis |
 Treatment & Medication: Torticollis |
| Follow-up: Torticollis |
| Multimedia: Torticollis |
| References |
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Further Reading
Keywords
retrocollis, anterocollis, laterocollis, rotational torticollis, spasmodic torticollis, cervical dystonia, idiopathic cervical dystonia, segmental dystonia of head and neck, head and neck dystonia, head tremor, head tilt, head jerks, head spasms
