What medications are used to treat hemiballismus?

Pharmacologic Management of Hemiballismus

First-line treatment for hemiballismus consists of dopamine D2 receptor blocking agents, with haloperidol being the most established option, started at low doses (0.5-2 mg) and titrated upward until movements are controlled. 1, 2

Primary Pharmacologic Options

Typical Antipsychotics (First-Line)

• Haloperidol is the most well-established treatment with a proven track record for suppressing ballistic movements 1, 3, 2

  • Start at 0.5-2 mg daily and titrate gradually as tolerated until movements are controlled 2, 4
  • Low-dose haloperidol (as low as 0.5 mg) can be effective while minimizing extrapyramidal side effects 4
  • In older patients, be cautious of extrapyramidal symptoms and cardiovascular effects 5

• Chlorpromazine is another effective typical antipsychotic for hemiballismus 1, 3

  • Useful for severe agitation accompanying the movement disorder 5
  • Caution: hypotensive effects limit use to bed-bound patients when given intravenously 5

• Perphenazine has been used successfully in small series for ballistic movements 2

• Sulpiride may be preferred as first-choice medication in older patients due to fewer side effects compared to haloperidol or chlorpromazine 3

Atypical Antipsychotics (Alternative First-Line)

• Olanzapine has demonstrated significant efficacy in reducing hemiballismus with potentially fewer extrapyramidal side effects 6, 2

  • In one quantified case, olanzapine reduced upper extremity ballistic movements from 23.5 to 3.0 per session and lower extremity movements from 20.5 to 7.0 per session 6
  • Start at 2.5 mg daily at bedtime, maximum 10 mg daily 5
  • Generally well tolerated with reduced risk of tardive dyskinesia compared to typical antipsychotics 5

• Risperidone has been used in small series with reduced risk of extrapyramidal symptoms 2

  • Start at 0.25 mg daily at bedtime, maximum 2-3 mg daily 5
  • Extrapyramidal symptoms may occur at doses ≥2 mg daily 5

• Quetiapine is another atypical option with lower extrapyramidal risk 5

  • Start at 12.5 mg twice daily, maximum 200 mg twice daily 5
  • More sedating; monitor for orthostatic hypotension 5

• Clozapine may have reduced risk of extrapyramidal side effects but requires careful monitoring 2

Second-Line Pharmacologic Options

Catecholamine-Depleting Agents

• Tetrabenazine should be considered when long-term therapy is required 1, 2

  • Particularly useful for persistent hemiballismus requiring extended treatment 1
  • Depletes presynaptic dopamine stores, providing an alternative mechanism to receptor blockade 2

• Reserpine is another catecholamine-depleting option for long-term management 2

Treatment Algorithm

1. Initiate dopamine D2 receptor blocker immediately:

   • Start with haloperidol 0.5-2 mg daily OR olanzapine 2.5 mg daily 1, 6, 2, 4
   • In elderly patients (≥65 years), consider sulpiride or atypical antipsychotics first to minimize extrapyramidal effects 3, 5

2. Titrate dose every 2-3 days based on response:

   • Increase gradually until movements are adequately controlled 2, 4
   • Monitor for extrapyramidal symptoms, sedation, and cardiovascular effects 5

3. If inadequate response or intolerable side effects:

   • Switch to an atypical antipsychotic (olanzapine, risperidone, or quetiapine) 6, 2
   • Consider adding or switching to tetrabenazine for persistent cases 1, 2

4. For refractory cases with severe agitation:

   • Add benzodiazepine (lorazepam) only after therapeutic neuroleptic levels are achieved to prevent paradoxical excitation 5

Critical Considerations

Natural history: Most cases of vascular hemiballismus show gradual spontaneous improvement within days to weeks, allowing eventual medication withdrawal 1, 3, 2. However, hemiballismus from non-vascular causes tends to persist longer and requires more intensive treatment 3.

Underlying etiology: Always treat the underlying cause concurrently—stroke, nonketotic hyperglycemia, or HIV-related complications are most common 1, 2. Elderly patients with severe hyperglycemia may experience complete resolution with glucose control alone 1, 2.

Avoid monotherapy with benzodiazepines: These should never be used as initial treatment and only added to established neuroleptic therapy for refractory agitation 5.

Surgical options: For the minority of patients with severe, persistent, disabling hemiballismus unresponsive to medications, pallidotomy or other stereotactic procedures may be considered 1, 2.