What are the treatment options for torticollis?

Treatment of Torticollis

For acute torticollis, initiate multimodal analgesia with NSAIDs as first-line therapy combined with heat application and gentle stretching exercises, while for congenital muscular torticollis (CMT), begin physical therapy and stretching within the first year of life to avoid surgical intervention. 1

Acute Torticollis Management

Initial Pharmacological Approach

• NSAIDs serve as the primary analgesic for pain control and inflammation reduction 1
• Add muscle relaxants to the NSAID regimen to reduce muscle spasm 1
• For severe pain with significant inflammation, consider a short course of oral corticosteroids 1
• Avoid benzodiazepines as they are conditionally recommended against for musculoskeletal pain 1

Non-Pharmacological Interventions

• Apply heat therapy directly to tense muscles to improve blood circulation 1
• Implement gentle stretching exercises to restore normal range of motion 1
• Ensure proper head positioning during rest and sleep 1
• Initiate supervised postural exercises and manual trigger point therapy 1

Red Flags Requiring Urgent Evaluation

• Progressive neurological symptoms suggesting spinal cord compression require immediate imaging 1
• In elderly patients, scalp tenderness with jaw claudication suggests giant cell arteritis and demands urgent evaluation 2

Congenital Muscular Torticollis (CMT)

Conservative Management (First-Line)

• Physical therapy with stretching exercises should begin within the first year of life for optimal outcomes 3
• Observation combined with physical therapy, with or without bracing, is effective in most cases when started early 3
• Continue conservative treatment for at least 6-12 months before considering other interventions 4, 3

Botulinum Toxin Injection (Second-Line)

• For recalcitrant idiopathic muscular torticollis (IMT) that fails conservative therapy, botulinum toxin type A injection into the affected sternocleidomastoid muscle is safe and effective 5
• This approach successfully avoided surgical release in 14 of 15 children with resistant IMT 5
• Botulinum toxin serves as an effective intermediate treatment before considering surgery 3
• Continue additional physiotherapy following botulinum toxin injection 5

Surgical Management (Third-Line)

• Surgery is indicated for classical CMT unresponsive to physiotherapy and forceful stretching, ideally performed before school age but after age 1 year 4
• The most reliable surgical technique is inferior open tenotomy of the sternal and clavicular heads of the sternocleidomastoid muscle 4
• Place incisions low in the neck along skin lines, not over the clavicle, to avoid hypertrophic scarring 4
• Release all restricting bands involving the sternocleidomastoid and other neck structures 4
• Move the head and neck through full range of motion before completing the procedure 4
• Resume physical therapy within 2 weeks post-operatively to prevent recurrent scar contracture 4, 6

Surgical Timing Considerations

• Early surgical intervention (before school age) maximizes reversal of craniofacial asymmetry due to greater growth potential 4
• Patients presenting after age 1 year have increased rates of requiring sternocleidomastoid lengthening 3
• Surgery may improve range of motion but not necessarily plagiocephaly, facial asymmetry, or cranial molding in older children 3

Pediatric-Specific Considerations

Diagnostic Evaluation

• Rule out ocular causes such as eye muscle weakness that may present as torticollis 1
• Consider imaging studies only if no improvement occurs with initial management or if neurological symptoms develop 1
• Magnetic resonance imaging of the brain and neck is no longer considered cost-effective or necessary in CMT 3
• Perform cervical spine radiographs as part of the systematic work-up 3

Additional Pain Management in Children

• Consider acetaminophen or ibuprofen for additional pain relief during the first 24-48 hours 1

Adjunctive Therapies

• Frequency-specific microcurrent combined with massage, stretching, and strengthening may achieve excellent outcomes in severe cases with fibrotic nodules 7

Important Caveats

Differentiate muscular from non-muscular torticollis, as missing non-muscular causes (inflammatory, ocular, neurologic, or orthopedic) could be life-threatening 3. The sternocleidomastoid "tumor" or mass in congenital torticollis requires no specific treatment and typically resolves spontaneously 4.

For ocular-related torticollis presenting with vertical diplopia and head tilt, treatment targets include improved binocular vision, diplopia control, and reduced tilt of subjective visual vertical 8. These cases may require prism glasses for small deviations or surgical intervention for larger incomitant deviations 8.