What should I do if I experience hallucinations while taking tizanidine (Zanaflex)?

Management of Hallucinations While Taking Tizanidine

If you experience hallucinations while taking tizanidine, discontinue the medication immediately and contact your healthcare provider, as this is a documented adverse effect that requires prompt medical attention. 1

Understanding Tizanidine-Related Hallucinations

Tizanidine (Zanaflex) is an α2-adrenergic receptor agonist used as a centrally acting muscle relaxant. The FDA drug label explicitly identifies hallucinations as a recognized adverse effect:

• Formed, visual hallucinations or delusions have been reported in approximately 3% of patients in controlled clinical studies 1
• These typically occur within the first 6 weeks of treatment 1
• Most patients are aware the hallucinations are not real 1
• Some cases may persist for weeks after discontinuation 1

Immediate Management Steps

1. Stop taking tizanidine - Hallucinations indicate a serious adverse reaction requiring immediate discontinuation
2. Contact healthcare provider - Inform them about the hallucinations and follow their guidance
3. Do not drive or operate machinery - Hallucinations combined with tizanidine's sedative effects create significant safety risks
4. Have someone stay with you - If hallucinations are severe or causing distress, don't remain alone

Important Considerations for Discontinuation

When stopping tizanidine, especially after long-term use, be aware that abrupt discontinuation can cause withdrawal symptoms:

• Rebound tachycardia, hypertension, and hypertonia 2, 3
• Visual and auditory hallucinations 2
• Anxiety, agitation, and delirium 2
• Tremors 4, 5

For patients on long-term therapy, a gradual taper is strongly recommended rather than abrupt discontinuation 3, 5. Your healthcare provider will determine an appropriate tapering schedule based on your current dosage and duration of treatment.

Medical Evaluation

Your healthcare provider will likely:

1. Assess the nature and severity of hallucinations
2. Review your complete medication list for potential drug interactions
   • Particularly important with CYP1A2 inhibitors (ciprofloxacin, fluvoxamine) 2
   • Interactions with other CNS depressants that may potentiate effects
3. Evaluate liver function, as tizanidine can cause liver injury 1
4. Consider alternative muscle relaxants based on your condition

Alternative Treatments

After experiencing hallucinations with tizanidine, your provider may consider alternative muscle relaxants such as:

• Cyclobenzaprine - Though it also has anticholinergic effects that can cause hallucinations in some patients 2
• Baclofen - Note that it also requires gradual discontinuation to avoid withdrawal 2
• Methocarbamol - May have fewer CNS side effects 2
• Metaxalone - Alternative with different side effect profile 2

Prevention of Future Episodes

To prevent similar reactions with future medications:

1. Always inform healthcare providers about your history of hallucinations with tizanidine
2. Be particularly cautious with other α2-adrenergic agonists or centrally acting muscle relaxants
3. Start any new muscle relaxant at the lowest possible dose with gradual titration
4. Report any unusual symptoms promptly to your healthcare provider

When to Seek Emergency Care

Seek immediate emergency care if hallucinations are accompanied by:

• Confusion or severe agitation
• Inability to distinguish reality from hallucinations
• Thoughts of self-harm or harm to others
• High fever, severe hypertension, or extreme tachycardia (possible withdrawal syndrome) 4, 5

Remember that hallucinations are a serious side effect requiring prompt medical attention, and proper management includes both addressing the immediate symptoms and planning for appropriate alternative treatments.