What are the options to manage a patient with uncontrolled jaw movements, potentially related to tardive dyskinesia (TD), who has been taking trazodone (trazodone) 100 mg every night (qhs) for years?

Management of Suspected Trazodone-Induced Tardive Dyskinesia

Discontinue trazodone immediately, as this is the primary treatment for drug-induced movement disorders, and the uncontrolled jaw movements are likely tardive dyskinesia (TD) or tardive oromandibular dystonia caused by this medication. 1, 2

Understanding the Clinical Situation

While trazodone is not a typical dopamine receptor-blocking agent, it can rarely cause tardive movement disorders:

• Trazodone-induced tardive oromandibular dystonia is extremely rare but well-documented, with case reports showing jaw and facial movement abnormalities after chronic use 3, 4
• The patient's presentation of uncontrolled jaw movements after years of trazodone use is consistent with tardive oromandibular dystonia, which presents as involuntary jaw movements, facial grimacing, and chewing motions 1, 3
• One case report demonstrated complete resolution of tardive dystonia within 3 days of discontinuing trazodone in a patient who had been on the medication long-term 4

Immediate Management Steps

1. Discontinue Trazodone

• Stop trazodone immediately if clinically feasible, as medication discontinuation is the primary treatment for drug-induced dyskinesia 1, 2
• Gradual taper over 10-14 days may limit withdrawal symptoms, though in documented trazodone-induced TD cases, rapid discontinuation led to symptom improvement 5, 4
• Monitor for improvement over the next few days to weeks, as early discontinuation offers the best chance for symptom resolution 1, 4

2. Alternative Sleep Management

Since trazodone was prescribed for sleep (qhs dosing):

• Consider non-pharmacologic sleep interventions first (sleep hygiene, cognitive behavioral therapy for insomnia) to avoid further medication exposure 6
• If medication is necessary for insomnia, alternatives include:
  • Short-acting benzodiazepines (lorazepam, temazepam) or zolpidem at low doses for short-term use, though these carry risks of tolerance and dependence 5
  • Melatonin or melatonin receptor agonists as safer alternatives
  • Low-dose mirtazapine (7.5-15 mg) if antidepressant properties are also needed

3. Document and Monitor

• Perform baseline assessment using the Abnormal Involuntary Movement Scale (AIMS) to objectively document the severity of jaw movements 1, 2
• Monitor every 1-2 weeks initially after trazodone discontinuation to assess for improvement 1
• Document the temporal relationship between trazodone use and symptom onset for the medical record 3

If Symptoms Persist After Trazodone Discontinuation

Rule Out Other Causes

• Review all current medications for other potential causative agents, particularly:
  • Antipsychotics (typical or atypical) 1, 7
  • Metoclopramide or other antiemetics with dopamine-blocking properties 1, 2
  • Any medication history from emergency department visits where antipsychotics may have been administered 2

Consider Pharmacologic Treatment for Persistent TD

If jaw movements persist 4-8 weeks after trazodone discontinuation:

• For moderate to severe or disabling TD, treat with a VMAT2 inhibitor (valbenazine or deutetrabenazine) as first-line pharmacotherapy 1, 8
• These are the only FDA-approved medications specifically for tardive dyskinesia and have demonstrated efficacy in class 1 studies 1
• Do NOT use anticholinergic medications (benztropine, trihexyphenidyl) for TD—they are contraindicated for tardive dyskinesia and indicated only for acute dystonia or drug-induced parkinsonism 1, 8

Critical Pitfalls to Avoid

• Do not increase or add antipsychotic medications, as this may temporarily mask symptoms but will worsen TD long-term 1, 7
• Do not prescribe anticholinergics for these jaw movements, as they are ineffective for TD and may worsen symptoms 1, 8
• Do not assume this is anxiety or stress-related movement without first addressing the medication cause 2
• Trazodone should be prescribed with extreme caution in patients taking other medications with potential to cause tardive syndromes, as the risk may be additive 3

Prognosis

• Early identification and prompt discontinuation offer the best chance for symptom resolution 1, 3, 4
• In documented cases of trazodone-induced tardive dystonia, symptoms improved rapidly (within days) after medication discontinuation 4
• However, TD may persist indefinitely even after medication discontinuation in some cases, making early intervention critical 1, 2
• Up to 50% of patients on chronic dopamine-blocking agents may experience some form of tardive or withdrawal dyskinesia 1, 2