What are the indications for tizanidine?

Tizanidine Indications

Tizanidine is FDA-approved for the management of spasticity (increased muscle tone), with treatment reserved for daily activities and times when relief of spasticity is most important. 1

FDA-Approved Indication

• Tizanidine is indicated as a short-acting drug for managing spasticity, specifically for upper motor neuron syndromes including stroke, multiple sclerosis, and spinal cord injury. 1, 2
• The medication should be reserved for those daily activities and times when relief of spasticity is most important due to its short duration of effect. 1

Specific Clinical Scenarios for Use

Spasticity-Related Complications

• Tizanidine is recommended for chronic stroke patients with spasticity resulting in pain, poor skin hygiene, or decreased function. 3, 4
• The American Heart Association specifically endorses tizanidine for these indications in chronic stroke patients, with maintained antispastic efficacy over time. 5

Multiple Sclerosis

• Tizanidine produces a 20% mean reduction in muscle tone in MS patients, with approximately 75% reporting subjective improvement without increased muscle weakness. 6
• The medication achieves maximum effect on spasticity within 1 week of starting treatment, with benefit maintained for at least 1 week after discontinuation. 6

Spinal Cord Injury

• Tizanidine significantly reduces muscle tone (assessed by Ashworth score) in patients with spinal cord injury of >12 months' duration, without significant alterations in muscle strength. 7

Off-Label Use (Not FDA-Approved)

Acute Low Back Pain

• The American College of Physicians recognizes tizanidine as an option for short-term relief of acute low back pain, though this is not an FDA-approved indication. 4, 5
• When used for low back pain, treatment duration in clinical trials was typically 2 weeks or less. 4
• Combining tizanidine with paracetamol provides superior short-term pain relief in patients with acute muscle spasms and back pain, though this increases the risk of CNS side effects (sedation and dizziness). 5

Critical Contraindications and Inappropriate Uses

Hypotonia (Reduced Muscle Tone)

• Tizanidine is specifically contraindicated for hypotonia—it treats increased muscle tone (spasticity), not reduced muscle tone. 2, 4
• Using tizanidine in hypotonia would worsen the underlying condition by further reducing muscle tone. 2

Stroke Recovery Period

• Unlike diazepam or other benzodiazepines, tizanidine is not contraindicated during stroke recovery. 4
• Diazepam and benzodiazepines should be avoided during stroke recovery due to possible deleterious effects on recovery, in addition to sedation side effects. 3

Stepwise Treatment Algorithm

• Tizanidine represents a second-line intervention after conservative measures (positioning, passive stretching, range of motion exercises) have been attempted. 3
• For patients who do not respond to oral medications like tizanidine, more invasive options should be considered: botulinum toxin injections, phenol/alcohol blocks, intrathecal baclofen, or neurosurgical procedures (selective dorsal rhizotomy or dorsal root entry zone lesion). 3, 4

Common Pitfall to Avoid

• Do not confuse spasticity (velocity-dependent hyperactivity of tonic stretch reflexes) with general muscle weakness or hypotonia—tizanidine will only benefit the former and may harm the latter. 3, 2