What are the initial management recommendations for acute torticollis?

Management of Acute Torticollis

The initial management of acute torticollis should focus on pain relief through muscle relaxants, NSAIDs, and gentle stretching exercises, with most cases resolving within days to weeks with conservative treatment. 1

Causes and Assessment

• Acute torticollis commonly results from inflammatory processes that irritate cervical muscles, nerves, or vertebrae, presenting as unilateral spasm of the sternocleidomastoid muscle with head positioning where the occiput rotates to the affected side and chin to the contralateral side 1
• Common causes include upper respiratory infections, sinusitis, otomastoiditis, cervical adenitis, and retropharyngeal abscess or cellulitis 1
• In children, careful evaluation for overt or occult otolaryngologic infections is essential, as these are frequent triggers 1
• Benign paroxysmal torticollis (BPT) presents as recurrent episodes of abnormal, painless head postures, typically with onset before 3 months of age 2

Initial Management Approach

• Implement multimodal analgesia combining non-opioid analgesics and muscle relaxants to control pain and reduce muscle spasm 2
• Apply heat therapy to relax tense muscles and improve blood circulation to the affected area 2
• Consider gentle stretching exercises to gradually restore normal range of motion 2
• Ensure proper positioning during rest and sleep to prevent worsening of symptoms 2
• For inflammatory causes, treat the underlying infection with appropriate antibiotics if bacterial etiology is suspected 1

Pharmacological Management

• NSAIDs are recommended as first-line agents for pain control and reducing inflammation 2
• Muscle relaxants such as cyclobenzaprine or baclofen may help reduce muscle spasm and associated pain 3
• For severe cases with significant pain, a short course of oral corticosteroids may be considered to rapidly reduce inflammation 2
• Avoid benzodiazepines as they have been conditionally recommended against in the management of musculoskeletal pain conditions 2

Physical Therapy Interventions

• Gentle manual therapy techniques including mobilization and trigger point therapy can help reduce muscle tension 2
• Supervised postural exercises and stretching with or without manual trigger point therapy have shown benefit 2
• Home exercise programs focusing on gentle stretching and strengthening of neck muscles should be implemented 2
• For persistent cases, consider head halter traction of three to four pounds' weight for five to seven days to determine if the condition will resolve with conservative management 4

When to Consider Advanced Interventions

• If symptoms persist beyond 7-10 days despite conservative management, further investigation with imaging (CT or MRI) should be performed 1
• For cases with atlantoaxial subluxation (which can occur as a result of inflammatory processes), orthopedic or neurosurgical consultation is warranted 1
• In persistent, disabling cases of spasmodic torticollis, botulinum toxin injections into affected muscles have shown 95% effectiveness rate with moderate to excellent improvement in 76% of treatments 5
• Surgical interventions should only be considered for refractory cases or when structural abnormalities are identified 6

Red Flags Requiring Urgent Evaluation

• Progressive neurological symptoms or signs suggesting spinal cord compression 2
• Fever with nuchal rigidity, which may indicate meningitis 1
• History of trauma preceding the onset of symptoms 6
• Persistent torticollis despite appropriate conservative management for 7-10 days 4

Follow-up and Monitoring

• Most cases of acute inflammatory torticollis resolve within days to weeks with appropriate conservative management 1
• Regular reassessment is necessary to monitor progress and adjust treatment as needed 4
• If symptoms worsen or fail to improve with initial management, prompt reevaluation and consideration of additional imaging or specialist consultation is warranted 1