Emergency treatment of movement disorders

Movement disorder emergencies occur in both hypokinetic and hyperkinetic patients. Prompt recognition of these emergencies is crucial, and diagnosis is based on history and phenomenology. Supportive and temporizing measures must be implemented immediately before disease-specific therapy is begun. For neuroleptic malignant syndrome and related conditions, we recommend a three-tier approach depending on severity, starting with benzodiazepines, dopamine agonists or levodopa, and dantrolene or electroconvulsive therapy. Methylprednisolone pulse therapy also is beneficial for neuroleptic malignant syndrome due to abrupt medication withdrawal in patients with Parkinson's disease. In treatment of other acute antidopaminergic-induced emergencies, anticholinergics usually suffice. To manage airway obstruction related to movement disorders, we rely on laryngoscopic evaluation to determine whether noninvasive or invasive interventions are needed. Hyperkinetic emergencies are treated individually based on the type of abnormal movements. If an antidopaminergic is needed, we prefer a dopamine depletor to a dopamine receptor blocker because of the risk of tardive syndromes with the latter. When focal hyperkinetic movements dominate the picture, botulinum toxin injection is a useful adjunct to medications.