What is the treatment for an oculogyric crisis?

Treatment of Oculogyric Crisis

Administer anticholinergic medications immediately—either benztropine 1-2 mg IM/IV or diphenhydramine 50 mg IM/IV—as first-line treatment for oculogyric crisis, which typically provides rapid symptom relief within minutes to one hour. 1, 2, 3

Immediate Acute Management

First-Line Pharmacologic Treatment

• Benztropine (Cogentin): Administer 1-2 mg intramuscularly or intravenously for immediate relief of acute dystonic reactions including oculogyric crisis 1, 2

  • The FDA label indicates improvement is sometimes noticeable within minutes after injection, with no significant difference between IV and IM routes 2
  • If symptoms begin to return, the dose can be repeated 2

• Diphenhydramine (Benadryl): Give 50 mg IM/IV as an alternative anticholinergic agent 1, 3

  • In one case report, 50 mg oral diphenhydramine resolved oculogyric crisis symptoms within one hour 3
  • Diphenhydramine was historically combined with metoclopramide to reduce the risk of oculogyric crisis 4

Critical Safety Consideration

• Recognize laryngeal dystonia as a medical emergency: Oculogyric crisis can be accompanied by laryngospasm presenting as choking, difficulty breathing, or stridor—this requires immediate anticholinergic treatment as it can be life-threatening 1

Ongoing Management After Acute Resolution

Short-Term Continuation Therapy

• Continue oral anticholinergic therapy for several days after the acute episode to prevent recurrence 5
• For drug-induced extrapyramidal disorders that develop soon after neuroleptic initiation, benztropine 1-2 mg two to three times daily usually provides relief within one to two days 2
• After one to two weeks, attempt withdrawal to determine continued need 2

Addressing the Underlying Cause

If the oculogyric crisis was medication-induced:

• Reduce or discontinue the offending agent if clinically feasible 6

  • In case series, some patients improved with dose reduction of the causative antipsychotic (aripiprazole, amisulpride) 6
  • Others required switching to alternative agents with lower dystonic risk 6

• Consider prophylactic anticholinergics if high-risk dopamine-blocking medications cannot be avoided, particularly in young males or those with previous dystonic reactions 1

Refractory Cases

• Switch to clozapine for patients who do not respond to anticholinergics and require ongoing antipsychotic therapy 6, 7
  • Two cases in a published series failed to improve with anticholinergic agents but stabilized after switching to clozapine 6
  • Clozapine is recommended as a long-term treatment strategy for chronic oculogyric crisis 7

Clinical Context and Pathophysiology

• Oculogyric crisis represents an acute dystonic reaction characterized by sustained, bilateral, upward deviation of the eyes 3, 5
• The underlying mechanism involves an imbalance between cholinergic and dopaminergic pathways 5
• Most commonly caused by antidopaminergic medications including typical antipsychotics, atypical antipsychotics (though less common), and antiemetics like metoclopramide 6, 5, 8
• Risk factors include male gender, young age, drug-naive status, and use of typical antipsychotics 3

Common Pitfalls to Avoid

• Do not delay treatment: Anticholinergics work rapidly and should be administered immediately upon recognition 1, 2
• Do not assume atypical antipsychotics are risk-free: While less common than with typical antipsychotics, oculogyric crisis can occur with atypicals including aripiprazole, olanzapine, quetiapine, amisulpride, and lurasidone 6, 3
• Do not forget to assess for laryngeal involvement: Check for stridor, choking, or breathing difficulty as this constitutes a medical emergency 1
• Do not abruptly discontinue other antiparkinsonian agents if benztropine is being initiated for chronic management—taper gradually if needed 2