Recommended Muscle Relaxant for Acute Torticollis
For acute torticollis, cyclobenzaprine 5 mg three times daily is the recommended muscle relaxant, as it is FDA-approved for acute painful musculoskeletal conditions and provides effective relief with lower sedation compared to the 10 mg dose. 1, 2
Primary Treatment Approach
- Cyclobenzaprine is FDA-indicated specifically as an adjunct to rest and physical therapy for relief of muscle spasm associated with acute, painful musculoskeletal conditions 1
- The optimal dosing is 5 mg three times daily, which provides equivalent efficacy to 10 mg TID but with significantly less sedation 2
- Treatment should be limited to 2-3 weeks maximum, as adequate evidence for longer use is not available and acute muscle spasm is generally self-limited 1
- Onset of relief occurs within 3-4 doses of the 5 mg regimen 2
Alternative Muscle Relaxant Option
- Tizanidine is an alternative choice if cyclobenzaprine is not tolerated, starting at 2-4 mg with upward titration as needed 3
- Tizanidine demonstrated efficacy in multiple trials for acute musculoskeletal pain and is preferred by the American College of Physicians for its efficacy and safety profile 3
- However, tizanidine requires monitoring for hepatotoxicity (generally reversible) 3
Important Clinical Considerations
Efficacy Evidence
- In randomized controlled trials of 1,405 patients with acute muscle spasm, cyclobenzaprine 5 mg TID showed significantly higher efficacy scores compared to placebo (P ≤0.001) on all primary measures including pain relief, medication helpfulness, and clinical global improvement 2
- The therapeutic effect is independent of sedation, as meaningful treatment effects were observed even in patients who did not report somnolence 2
Safety Profile
- Somnolence and dry mouth are the most common adverse effects, occurring in a dose-dependent manner 2
- Overall adverse events occurred in 54-62% of cyclobenzaprine patients versus 35% with placebo 2
- All skeletal muscle relaxants increase CNS adverse events (RR 2.04; 95% CI 1.23-3.37), but serious complications are rare and most adverse events are self-limited 3
Medications to Avoid
- Benzodiazepines (diazepam) are not preferred due to abuse potential, despite showing similar efficacy to cyclobenzaprine 3
- Baclofen and dantrolene have sparse evidence for acute musculoskeletal pain despite efficacy in spasticity 3
- Cyclobenzaprine 2.5 mg TID is not effective, showing no significant difference from placebo 2
Combination Therapy Consideration
- Adding a muscle relaxant to an NSAID or acetaminophen provides greater short-term pain relief than analgesic monotherapy 4, 3
- This combination increases CNS adverse events (RR 2.44) but may reduce gastrointestinal adverse events (RR 0.54) 3
Critical Pitfall to Avoid
Do not confuse acute torticollis (wry neck from muscle spasm) with congenital muscular torticollis or dystonic torticollis - the latter conditions require different management approaches including physical therapy, Botox injections, or treatment of underlying neurologic/orthopedic causes 5, 6. Acute torticollis presenting in adults is a painful musculoskeletal condition amenable to muscle relaxant therapy, while congenital torticollis in infants primarily requires stretching exercises 5.