QuestionSBA
QuestionChoice
This patient is presenting with acute dystonia in the form of torticollis (cervical dystonia) and an oculogyric crisis. Ondansteron is an antiemetic particularly used in the case of nausea and vomiting caused by chemotherapy. It is a serotonin 5 HT3 receptor antagonist. It does not have any effect on the D2 receptors; therefore, acute dystonias are not a recognised side effect.
52901
e
Ondansetron
QuestionChoice
This patient is presenting with acute dystonia in the form of torticollis (cervical dystonia) and an oculogyric crisis. Metoclopramide is primarily a D2 receptor antagonist and acts on the receptors in the chemoreceptor trigger zone in the central nervous system. It is also a prokinetic agent via its muscarinic activity. Due to antagonism at the D2 receptor, it may also cause blockade in the extrapyramidal circuits, leading to side effects including acute dystonia (such as oculogyric crises and cervical dystonias), and, with chronic use, tardive dyskinesias. The risk of acute dystonic reactions is increased with higher doses and younger patients.
52897
a
Metoclopramide
QuestionChoice
This patient is presenting with acute dystonia, in the form of torticollis (cervical dystonia) and an oculogyric crisis. Cyclizine is a histamine H1 receptor antagonist. Side effects may include urinary retention but extrapyramidal side effects are not reported.
52898
b
Cyclizine
QuestionChoice
This patient is presenting with acute dystonia in the form of torticollis (cervical dystonia) and an oculogyric crisis. Chlopromazine is an antipsychotic that antagonises the D2 receptor and would not ordinarily be used to treat nausea and vomiting. Less commonly, it causes acute dystonias but it is known to cause tardive dyskinesia and akathisia, which are more likely at higher doses.
52899
c
Chlopromazine
QuestionChoice
This patient is presenting with acute dystonia in the form of torticollis (cervical dystonia) and an oculogyric crisis. Promethazine is a first-generation antihistamine, antagonising the H1 receptor, and is generally used for its sedative effects, as opposed to its antiemetic effects. It has some antidopaminergic effects, which may lead to tardive dyskinesia, dystonias and akathisia but these are uncommon.
52900
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Promethazine
QuestionComment
does this hurt the fish
24016
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subscriber
Recessive Hallux
QuestionComment
This is an unfair question, chlopromazine is one of the anti-nausea medications recommended for treating N&V in pregnancy. It is also a typical antipsychotic- hence may also lead to acute dystonias in the same way as metoclopromide 
28886
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subscriber
Relapse Otitis
QuestionComment
Metoclopramide is a second line anti-emetic in N&V in pregnancy. Chlorpromazine is first line and can also cause extra-pyramidal side effects.... 
61417
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subscriber
JAH 
Concept
Chapter
# Definition

Dystonias refer to a spectrum of movement disorders, characterised by involuntary muscle contractions leading to abnormal, often repetitive, movements and postures. These contractions can be prolonged and are often painful.

# Epidemiology

Dystonias are considered the third most common movement disorder, following tremor and Parkinson's disease. It can occur at any age, but the timing and type of dystonia may vary based on whether it's primary or secondary.

# Aetiology

* **Primary dystonias** are idiopathic in nature, often genetic, and can be generalised or focal. A known example is the autosomal dominant generalised dystonia, also known as Flatau-Sterling syndrome. This usually starts in childhood and commences in the lower limbs before spreading to the rest of the body. Focal dystonia is limited to one part of the body, such as musician's cramp or spasmodic torticollis (cervical dystonias).
* **Secondary dystonias** are usually attributable to specific causes or conditions, often related to drug use or neurological diseases. Common culprits include anti-dopaminergic drugs such as antipsychotics or anti-emetics (typically metoclopramide).

# Signs and symptoms

Common signs and symptoms of dystonia include:

* Prolonged muscle contractions
* Abnormal postures
* Repetitive movements
* Cramping or pain in the affected muscles
* Specific examples include: 
  * Oculogyric crisis - upward deviation of the eyes
  		* Commonly associated with starting a neuroleptic agent 
  * Torticollis or cervical dystonia - abnormal, often painful, neck positioning
  * Trismus or lockjaw - difficulty opening the mouth due to muscle spasm

# Differential diagnosis

Dystonias should be differentiated from other movement disorders and conditions that present with similar symptoms. Major differentials include:

* **Parkinson's disease**: Characterized by bradykinesia, rigidity, rest tremor, and postural instability.
* **Essential tremor**: Mainly causes action tremors, typically affecting the hands, head, or voice.
* **Tardive dyskinesia**: Typically caused by long-term use of neuroleptic drugs, it manifests as involuntary, repetitive body movements such as grimacing, sticking out the tongue, or smacking the lips.
* **Myoclonus**: Characterized by sudden, brief, involuntary muscle jerks.

# Investigations

Investigation of dystonia often includes:

* Detailed medical history
* Neurological examination
* Neuroimaging (e.g., MRI Head +- Spine)to assess for any structural cause
* Genetic testing, especially in suspected primary dystonias
* Evaluation of response to pharmacologic interventions


please can you re-group Mx section into primary and secondary dystonias. It’s a mid muddled here. Mainstay in secondary dystonia is stopping the offending drug e.g. neuroleptic/metoclopramide and managing the acute, painful dystonic reaction (with anticholinergics).

# Management

Management of dystonia depends on whether it is primary (genetic or idiopathic) or secondary (due to an external factor such as medication or another condition):

### Primary Dystonias
For primary dystonias (those that are genetic or idiopathic), the following treatments are often used:

* **Botulinum toxin injections**: Particularly effective for focal dystonias.
* **Oral medications**: These can include anticholinergics, benzodiazepines, and dopamine agonists to help manage symptoms.
* **Physical therapy**: Helps to manage muscle function and reduce disability.
* **Deep brain stimulation (DBS)**: Used for refractory cases that do not respond to other treatments.
* **Genetic counseling**: Recommended for patients and their families to understand hereditary aspects.

### Secondary Dystonias
In secondary dystonias (those caused by an identifiable external factor, such as medication):

* **Withdrawal of offending agents**: Stopping the neuroleptic or metoclopramide that triggered the dystonia is essential.
* **Management of acute dystonic reactions**: This often involves the use of anticholinergic medications to relieve painful muscle spasms.
* **Further pharmacological therapies**: Botulinum toxin injections and oral medications (e.g., anticholinergics, benzodiazepines) may still be useful in ongoing management.
* **Physical therapy**: Can aid in recovery and functional improvement.

# References

Jankovic J. Treatment of dystonia. Lancet Neurology. 2006;5(10):864-872. doi:10.1016/S1474-4422(06)70572-1

Albanese A, Bhatia K, Bressman SB, et al. Phenomenology and classification of dystonia: a consensus update. Movement Disorders. 2013;28(7):863-873. doi:10.1002/mds.25475

Cloud LJ, Jinnah HA. Treatment strategies for dystonia. Neurotherapeutics. 2011;8(4):722-730. doi:10.1007/s13311-011-0074-7


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Dystonia
Topic
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Neurology
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Metoclopramide can cause acute dystonia, including torticollis and oculogyric crises, particularly in younger patients and with higher doses.
A 33-year-old pregnant woman presents with persistent nausea and vomiting in the first trimester. She reports that she cannot keep any food down, and this has been the case for 5 d. She has managed small sips of water. On examination, she is tachycardic at 110 bpm, blood pressure 115/70 mmHg, respiratory rate 18 and is afebrile. A diagnosis of hyperemesis gravidarum is made by the admitting team and she is prescribed antiemetics and fluids. Two hours later the patient's head has rotated to one side and her eyes are periodically deviating upwards.

What is the most likely antiemetic to have caused this side effect?
a