What is the initial evaluation and management for an adult with recent‑onset acute torticollis without red‑flag symptoms?

Initial Evaluation and Management of Acute Torticollis in Adults

For an adult with recent-onset acute torticollis without red-flag symptoms, initiate multimodal analgesia with NSAIDs as first-line therapy, combined with heat application and gentle stretching exercises, while ruling out serious underlying causes through focused history and examination. 1, 2

Initial Clinical Assessment

Key History Elements to Obtain

• Onset characteristics: Acute torticollis typically presents with sudden neck stiffness and abnormal head positioning 3
• Associated symptoms requiring urgent attention:
  • Severe vertigo, dizziness, nausea, or vomiting (suggests vestibular pathology) 4
  • Motor or sensory changes, ataxia, or headache (suggests neurological involvement) 4
  • Vertical diplopia or subjective tilting of visual world (suggests skew deviation) 4
  • Fever or recent upper respiratory infection (suggests inflammatory etiology) 5
• Red-flag symptoms that mandate immediate imaging and specialist referral:
  • Progressive neurological deficits suggesting spinal cord compression 1, 2
  • In elderly patients: scalp tenderness with jaw claudication (giant cell arteritis) 1
  • History of malignancy, trauma, or intravenous drug use 4

Focused Physical Examination

• Musculoskeletal assessment: Palpate for cord-like sternocleidomastoid muscle tightness and trigger points 3, 6
• Neurological screening: Check for Horner's syndrome, cranial nerve palsies, internuclear ophthalmoplegia, nystagmus, hemiparesis, sensory loss, or ataxia 4
• Ocular examination: Rule out vertical diplopia and perform three-step test if ocular torticollis suspected 4
• Cervical spine palpation: Assess for vertebral body tenderness 4

Initial Management Without Red Flags

Pharmacological Approach

• NSAIDs as primary therapy: Serve as first-line analgesic for pain control and inflammation reduction 1, 2
• Add muscle relaxants: Combine with NSAIDs to reduce muscle spasm 1, 2
• Short course of oral corticosteroids: Consider for severe pain with significant inflammation 1, 2
• Avoid benzodiazepines: These are conditionally recommended against for musculoskeletal pain 1, 2

Non-Pharmacological Interventions

• Heat therapy: Apply directly to tense muscles for 15-20 minutes, 3-4 times daily to improve blood circulation 1, 2, 7
• Gentle stretching exercises: Implement to gradually restore normal range of motion 1, 2
• Proper positioning: Ensure correct head positioning during rest and sleep 1, 2
• Manual therapy: Initiate supervised postural exercises and manual trigger point therapy 1, 2

When to Image

Imaging is NOT Required Initially

• In the absence of red-flag symptoms, imaging may not be required at initial presentation, as most acute torticollis resolves with conservative management 4
• Spondylotic changes are commonly identified in patients >30 years and correlate poorly with neck pain presence 4

Imaging IS Required When

• Progressive neurological symptoms develop 1, 2
• No improvement occurs with initial management 1, 2
• Red-flag symptoms are present (trauma, malignancy, infection, systemic disease) 4
• MRI cervical spine is the preferred modality when imaging is indicated, as it provides superior soft-tissue contrast 4

Special Considerations

Ocular-Related Torticollis

If vertical diplopia and head tilt are present, this suggests skew deviation or superior oblique palsy requiring ophthalmology referral 4:

• Skew deviation may indicate brainstem, cerebellar, or vestibular pathology and warrants neurology or otolaryngology consultation 4
• Treatment targets: Improved binocular vision, diplopia control, and reduced tilt of subjective visual vertical 1
• Initial management: Prism glasses for small deviations; surgical intervention may be needed for larger incomitant deviations 1

Inflammatory Torticollis

If recent upper respiratory infection, sinusitis, or cervical adenitis is present, consider inflammatory etiology 5:

• These cases may require computed tomography to rule out retropharyngeal abscess or atlantoaxial subluxation 5

Common Pitfalls to Avoid

• Missing serious pathology: Always screen for red-flag symptoms before attributing torticollis to benign muscular causes 4
• Premature imaging: Avoid unnecessary imaging in uncomplicated cases without red flags, as findings often do not correlate with symptoms 4
• Overlooking ocular causes: Vertical diplopia with torticollis requires ophthalmology evaluation, not just musculoskeletal treatment 4, 1
• Using benzodiazepines: Despite their muscle relaxant properties, these are not recommended for musculoskeletal pain conditions 1, 2

Follow-Up Strategy

• Most cases resolve with conservative management within days to weeks 3
• If symptoms persist beyond 4-6 weeks or worsen despite treatment, reassess for underlying pathology and consider imaging 4, 1
• Refer to neurology if neurological symptoms develop, or to ophthalmology if ocular symptoms are present 4