From the Guidelines
Tizanidine and baclofen are both effective options for managing muscle spasms after stroke, with the most recent evidence from 2025 suggesting that oral baclofen may be a viable alternative to botulinum toxin for patients with focal spasticity 1.
Key Considerations
- Tizanidine typically starts at 2-4 mg taken 1-3 times daily, gradually increasing to a maximum of 36 mg per day divided into three doses.
- Baclofen usually begins at 5 mg three times daily, slowly increasing by 5 mg every three days until reaching an effective dose, typically 40-80 mg daily.
- Both medications work by different mechanisms - tizanidine is a central alpha-2 adrenergic agonist that reduces spasticity with less effect on muscle strength, while baclofen is a GABA-B receptor agonist that inhibits reflexes at the spinal cord level.
Side Effects and Monitoring
- Side effects differ between the medications: tizanidine commonly causes sedation, dry mouth, and dizziness, while baclofen may cause weakness, drowsiness, and confusion.
- Treatment should start at low doses with gradual increases to minimize side effects.
- Regular follow-up is important to assess effectiveness and manage any side effects.
Choice of Medication
- The choice between tizanidine and baclofen depends on the patient's specific symptoms, other medical conditions, and medication tolerances.
- Oral baclofen may be preferred for patients with focal spasticity, as it has been shown to be effective in reducing spasticity with minimal difference in efficacy compared to botulinum toxin 1.
From the FDA Drug Label
Tizanidine is a short-acting drug for the management of spasticity. Baclofen tablets are useful for the alleviation of signs and symptoms of spasticity resulting from multiple sclerosis, particularly for the relief of flexor spasms and concomitant pain, clonus, and muscular rigidity. The efficacy of baclofen in stroke, cerebral palsy, and Parkinson’s disease has not been established and, therefore, it is not recommended for these conditions.
Tizanidine can be used for the management of spasticity, but the label does not specifically mention its use after stroke.
- Baclofen is not recommended for use in stroke patients as its efficacy in this condition has not been established 2. Key consideration: The use of baclofen after stroke for spasm is not supported by the FDA drug label. Tizanidine may be considered for spasticity management, but its use after stroke is not directly addressed in the label 3.
From the Research
Tizanidine and Baclofen for Post-Stroke Spasm
- Tizanidine and baclofen are two medications commonly used to treat spasticity after a stroke 4, 5, 6.
- Baclofen is a general pharmacological treatment that can be used to manage post-stroke upper-limb spasticity, but it is limited by adverse events and lack of evidence of functional benefit 5.
- Tizanidine is an alpha(2)-adrenoceptor agonist that has been shown to be effective in managing spasticity associated with stroke, with comparable efficacy to baclofen or diazepam and favorable tolerability 6.
- Combination therapy with tizanidine and baclofen may be an effective way to control spasticity while managing dose-dependent adverse events, although additional studies are needed to confirm these results 6.
Comparison with Other Treatments
- Botulinum toxin type A (BTX-A) is another treatment option for post-stroke spasticity, which has been shown to be effective in reducing muscle tone in patients with post-stroke upper limb spasticity 4, 5, 7.
- Physical therapy interventions, such as transcutaneous electrical nerve stimulation, neuromuscular electrical stimulation, and resistance training, may also be effective in managing post-stroke spasticity, although the quality of evidence is moderate to low 8.
Clinical Considerations
- The choice of treatment for post-stroke spasticity should be individualized based on the patient's specific needs and circumstances 5, 6, 7.
- A multidisciplinary approach, including physical therapy and medical interventions, may be necessary to optimize outcomes for patients with post-stroke spasticity 8, 7.