Bupropion Use in Patients with History of Cervical Dystonia
Bupropion should be used with extreme caution or avoided in patients with a history of cervical dystonia, as there is documented evidence of bupropion-induced acute dystonia, including neck stiffness and jaw muscle spasm. 1
Evidence of Bupropion-Induced Dystonia
A case report documented acute dystonia consisting of neck stiffness, trismus, and temporomandibular joint complications in a patient taking bupropion SR. 1 The key findings include:
- Dose-dependent relationship: Symptoms appeared within 24-48 hours when bupropion SR was increased from 150 mg once daily to 150 mg twice daily (300 mg total). 1
- Symptom resolution: Dystonic symptoms resolved when the dose was reduced back to 150 mg once daily. 1
- Recurrence pattern: Upon rechallenge with the higher dose, neck and jaw symptoms recurred within 24-48 hours, confirming a probable causal relationship. 1
Mechanism and Clinical Implications
Bupropion interacts with both dopaminergic and serotonergic systems. 1 Acute dystonia is typically linked to dopamine depletion and basal ganglion dysfunction, with 90% of symptoms occurring within the first 3-5 days of starting or increasing medication dosage. 1
Critical caveat: Patients with pre-existing cervical dystonia may be at heightened risk for exacerbation or recurrence of dystonic symptoms when exposed to medications that affect dopaminergic pathways. 1
Practical Management Approach
If bupropion must be considered in a patient with history of cervical dystonia:
- Start at the lowest possible dose (150 mg SR once daily or less). 1
- Monitor closely within the first 48-72 hours after initiation or any dose increase for signs of neck stiffness, jaw tightness, or TMJ symptoms. 1
- Avoid dose escalation beyond 150 mg daily if any dystonic symptoms emerge. 1
- Consider alternative antidepressants that do not affect dopaminergic pathways as first-line options. 1
Alternative Treatment Considerations
For patients with cervical dystonia requiring treatment for depression or smoking cessation, consider:
- Selective serotonin reuptake inhibitors (SSRIs) as safer alternatives for depression, though they lack the smoking cessation benefits of bupropion. 2
- Botulinum toxin remains first-line therapy for the cervical dystonia itself, with proven efficacy for both motor symptoms and associated pain. 3, 4, 5
The risk of precipitating or worsening dystonic symptoms with bupropion in patients with cervical dystonia history outweighs potential benefits in most clinical scenarios.