What treatment options are available for a patient with continuous muscle spasms who has already been treated with baclofen (GABA receptor agonist) and diazepam (Valium, benzodiazepine)?

Management of Refractory Continuous Muscle Spasms

For continuous muscle spasms that have failed both baclofen and diazepam, consider tizanidine or dantrolene as the next oral agent, or proceed directly to botulinum toxin for focal spasms or intrathecal baclofen for severe generalized spasticity. 1

Critical First Step: Distinguish Spasticity from Other Muscle Disorders

Before escalating therapy, confirm the diagnosis:

• True spasticity (velocity-dependent increased muscle tone from upper motor neuron lesions) responds to GABA-ergic agents like baclofen 2
• Muscle spasms without spasticity may not respond to traditional antispasmodics and require different approaches 3
• Evaluate for underlying causes: CNS injury, demyelinating disease, stroke, or spinal cord pathology 3

Pharmacological Options After Baclofen and Diazepam Failure

Oral Alternatives for Generalized Spasticity

Tizanidine is the preferred next-line oral agent:

• Alpha-2 adrenergic agonist with different mechanism than baclofen 1
• Start low and titrate slowly in older adults 3
• Alternative to baclofen when GABA-B agonism has failed 1

Dantrolene acts peripherally on muscle:

• Works directly on skeletal muscle by inhibiting calcium release 1, 2
• Useful when central agents have failed 2
• Monitor liver function due to hepatotoxicity risk 2

Gabapentinoids (pregabalin or gabapentin) if neuropathic pain component:

• First-line for neuropathic pain in older adults 1
• Start pregabalin 25-50 mg/day or gabapentin 100-200 mg/day 3
• Titrate slowly to avoid somnolence and dizziness 3

Focal Spasticity: Botulinum Toxin is Superior

Botulinum toxin injections are strongly preferred over oral agents for focal muscle spasms:

• More effective than baclofen for focal spasticity 1
• Particularly useful for hand, limb, or specific muscle group involvement 1
• Avoids systemic side effects of oral medications 3, 1

Severe Refractory Spasticity: Intrathecal Baclofen

For severe, generalized spasticity unresponsive to maximum oral doses:

• Intrathecal baclofen via implanted pump delivers medication directly to spinal cord 1, 2
• Only 10% of systemic dose required for equivalent effect 1
• Studies show >80% improvement in muscle tone and >65% improvement in spasms 1
• Indicated when oral baclofen at 30-80 mg/day divided doses has failed 1

Critical Safety Considerations

Avoid Benzodiazepine Continuation

Diazepam should be discontinued, not continued:

• Benzodiazepines have limited efficacy for persistent muscle spasms 3
• No direct analgesic effect demonstrated 3
• High risk profile in older adults outweighs potential benefits 3
• May impair stroke recovery if used in that context 1

Baclofen Withdrawal Risk

Never abruptly discontinue baclofen:

• Abrupt cessation causes potentially life-threatening withdrawal syndrome 1, 4
• Symptoms include high fever, altered mental status, rebound spasticity, seizures 1
• Requires slow tapering if discontinuation planned 3

Treatment Algorithm

1. Confirm diagnosis of true spasticity vs. other muscle disorders
2. For focal spasms: Proceed directly to botulinum toxin 1
3. For generalized spasms: Trial tizanidine or dantrolene as next oral agent 1, 2
4. If neuropathic component: Add gabapentinoid (pregabalin preferred) 3, 1
5. For severe refractory cases: Consider intrathecal baclofen pump 1, 2
6. Discontinue diazepam due to limited efficacy and high risk 3, 1

Common Pitfalls to Avoid

• Do not use "muscle relaxants" (cyclobenzaprine, methocarbamol, carisoprodol): These do not actually relieve muscle spasm and have no evidence for chronic use 3
• Do not continue benzodiazepines long-term: Risk outweighs benefit except for end-of-life anxiety management 3
• Do not abruptly stop baclofen: Always taper slowly to prevent withdrawal syndrome 3, 1, 4
• Do not overlook non-pharmacological approaches: Physical therapy, stretching, positioning, and splinting remain first-line adjuncts 1