What is the best treatment for torticollis?

Treatment of Torticollis

For acute torticollis in adults, initiate multimodal therapy with NSAIDs as first-line treatment combined with heat application and gentle stretching exercises, adding muscle relaxants for significant muscle spasm. 1

Acute Torticollis Management (Adults)

First-Line Pharmacologic Treatment

• Start NSAIDs immediately as the primary analgesic for pain control and inflammation reduction 1
• Add muscle relaxants to the NSAID regimen when significant muscle spasm is present 1
• Consider a short course of oral corticosteroids for severe pain with significant inflammation 1
• Avoid benzodiazepines as they are conditionally recommended against for musculoskeletal pain 1

Physical Modalities

• 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 1

Congenital Muscular Torticollis (Pediatric)

Conservative Management (First-Line)

• Begin physical therapy with stretching and strengthening exercises within the first year of life for optimal outcomes 2
• Observation and physical therapy, with or without bracing, is effective in approximately 95% of cases when instituted early 3, 2
• Consider acetaminophen or ibuprofen for additional pain relief during the first 24-48 hours 1
• Massage combined with stretching and strengthening may accelerate resolution 4

Diagnostic Considerations

• Rule out ocular causes such as eye muscle weakness that may present as torticollis 1
• Obtain cervical spine radiographs as part of the initial work-up 2
• MRI of the brain and neck is no longer considered cost-effective or necessary in congenital muscular torticollis 2
• Consider imaging studies only if no improvement occurs with initial management or if neurological symptoms develop 1

Surgical Intervention

• Surgery is indicated for classical congenital muscular torticollis that does not respond to physiotherapy and forceful stretching 5
• The sternocleidomastoid "tumor" or mass requires no specific treatment and typically resolves spontaneously 5
• Surgery should be completed prior to school age (ideally between ages 1-5 years) to maximize reversal of craniofacial asymmetry during peak growth potential 5
• Inferior open tenotomy of the sternal and clavicular heads of the sternocleidomastoid muscle is the most popular and reliable surgical approach 5
• Place incisions low in the neck along skin lines, not over the clavicle, to avoid hypertrophic scarring 5
• Alternative techniques include bipolar release of the sternocleidomastoid muscle or subperiosteal lengthening at the mastoid insertion 6, 3
• Resume physical therapy within 2 weeks of surgery to prevent recurrent scar contracture 5

Prognosis by Age

• Patients presenting after age 1 year have an increased rate of requiring sternocleidomastoid muscle lengthening 2
• Surgery in older children or adults with long-standing disease yields only modest results for craniofacial asymmetry 5
• Surgery may improve range of motion but not necessarily plagiocephaly, facial asymmetry, or cranial molding in late presentations 2

Ocular-Related Torticollis

Treatment Approach

• Treatment targets include improved binocular vision, diplopia control, and reduced tilt of subjective visual vertical 1
• Small vertical deviations can be managed with prism glasses 1
• Larger incomitant deviations require surgical intervention for vertical diplopia and head tilt 1

Common Pitfalls

• Do not assume benign etiology without proper evaluation - torticollis can be a sign of serious underlying neuromuscular, infectious, or central nervous system disease 5, 2
• Missing nonmuscular torticollis could be potentially life-threatening 2
• Delaying surgery beyond school age in refractory congenital cases reduces the potential for reversing craniofacial asymmetry 5
• Failing to resume physical therapy promptly after surgery increases risk of recurrent scar contracture 5