What is the Drug of Choice for Spasticity?

October 12, 2025 •

4 min read

Affecting up to 11% of stroke survivors and many with spinal cord injuries, spasticity is a common neurological condition causing muscle stiffness and spasms. The question, What is the drug of choice for spasticity?, has no single answer, as the ideal medication depends on the cause, severity, and location of the spasticity.

Quick Summary

A guide to spasticity medications, covering oral options like baclofen and tizanidine, injectable botulinum toxins, and implantable pumps. The best choice is personalized based on an individual's condition.

Key Points

Personalized Treatment: There is no single drug of choice for spasticity; the best medication depends on the specific cause, severity, and whether the spasticity is localized or generalized.
Baclofen: A first-line oral treatment for generalized spasticity, especially from spinal cord injury and multiple sclerosis, acting centrally to reduce spasms.
Tizanidine: An oral muscle relaxant with comparable efficacy to baclofen but often used for short-term or nocturnal spasms due to its shorter half-life and potential for fewer side effects like muscle weakness.
Botulinum Toxin Injections: The preferred treatment for focal spasticity affecting specific muscle groups, offering temporary, targeted relief lasting three to four months.
Intrathecal Baclofen Therapy: A highly effective option for severe, generalized spasticity, involving an implanted pump that delivers medication directly to the spinal fluid with fewer systemic side effects.
Dantrolene: A peripherally acting medication that works directly on muscles, particularly useful for cerebral-origin spasticity but requires liver function monitoring.
Combined Approach: The most effective management often involves a combination of medication, physical therapy, and other rehabilitative techniques.

The Personalized Approach to Spasticity Medication

There is no one-size-fits-all drug of choice for spasticity, a motor disorder characterized by involuntary muscle spasms, stiffness, and exaggerated reflexes. The most effective treatment plan is highly personalized, determined by the underlying cause of spasticity, its severity, and whether it is localized or generalized. Conditions such as multiple sclerosis (MS), spinal cord injury (SCI), cerebral palsy (CP), and stroke all cause spasticity and may require different therapeutic strategies. Treatment often begins with physical and occupational therapy and progresses to medications, which can be taken orally for widespread spasticity or administered via injection for targeted relief. For severe, generalized cases, surgical options like an intrathecal pump may be considered.

Oral Medications for Generalized Spasticity

Oral muscle relaxants are typically the first line of pharmacological treatment for generalized spasticity. These centrally acting agents work in the brain and spinal cord to reduce muscle tone and spasms.

Baclofen (Lioresal)

Baclofen is often considered the first-line oral treatment for spasticity, particularly that resulting from spinal cord injury or multiple sclerosis. It is a GABA-B receptor agonist that inhibits the release of excitatory neurotransmitters in the spinal cord, which helps to decrease the frequency and severity of muscle spasms.

Administration: Available as tablets and an oral solution.
Efficacy: Very effective in managing spasticity originating from spinal or cerebral issues.
Side Effects: Common side effects include drowsiness, fatigue, weakness, and dizziness. Abruptly stopping high doses can lead to serious withdrawal symptoms.

Tizanidine (Zanaflex)

As a centrally acting alpha-2 adrenergic agonist, tizanidine reduces muscle tone by increasing presynaptic inhibition of motor neurons. Its relatively short half-life makes it useful for managing intermittent or nocturnal spasms.

Administration: Available in both tablets and capsules.
Efficacy: Often comparable in effectiveness to baclofen and diazepam, with some studies showing better patient tolerance and less muscle weakness.
Side Effects: Can cause dose-related drowsiness, hypotension, dry mouth, and liver enzyme elevation.

Dantrolene Sodium (Dantrium)

Unlike centrally acting drugs, dantrolene works directly on the skeletal muscles by inhibiting calcium release from the sarcoplasmic reticulum. This action directly affects the muscle contraction process.

Administration: Taken orally as capsules.
Indications: Particularly useful for cerebral-origin spasticity, such as that from traumatic brain injury or stroke.
Side Effects: The most serious side effect is liver toxicity, requiring monitoring of liver function. It can also cause generalized muscle weakness, which may be limiting for some patients.

Diazepam (Valium)

Diazepam, a benzodiazepine, facilitates the inhibitory effects of GABA-A receptors, leading to muscle relaxation and sedation. Its use is typically limited to short-term management due to its potential for tolerance and dependency.

Administration: Available in oral and other formulations.
Indications: Effective for spasticity related to SCI or MS, and often used to address nighttime spasms.
Side Effects: Significant sedation is a major limiting side effect.

Targeted Treatment: Injectables and Pumps

For spasticity that affects only a few specific muscle groups (focal spasticity) or for severe generalized cases, more targeted treatments are used.

Botulinum Toxin Injections (Botox, Dysport)

Botulinum toxin is a potent neurotoxin that is injected directly into spastic muscles to block the release of acetylcholine, causing temporary muscle relaxation.

Mechanism: Blocks nerve signals to the targeted muscles.
Indications: First-line treatment for focal spasticity, such as in the limbs after a stroke or in cerebral palsy.
Duration: Effects typically last for three to four months.
Side Effects: Generally well-tolerated, with side effects limited to the injection site.

Intrathecal Baclofen (ITB) Therapy

For severe, intractable generalized spasticity that does not respond to oral medications or causes intolerable side effects, an implanted pump can deliver baclofen directly into the spinal fluid.

Mechanism: Delivers baclofen directly to the central nervous system, bypassing the blood-brain barrier.
Efficacy: Allows for much higher concentrations of the drug at the site of action with fewer systemic side effects like drowsiness.
Indications: Primarily used for severe generalized spasticity, particularly in the lower limbs, from conditions like SCI or MS.

Comparison of Common Spasticity Medications


Feature	Baclofen (Oral)	Tizanidine (Oral)	Dantrolene (Oral)	Botulinum Toxin (Injectable)
Mechanism	Central GABA-B agonist	Central alpha-2 agonist	Peripheral muscle action	Blocks acetylcholine release
Best for	Spinal cord origin, MS	Short-term/nocturnal spasms	Cerebral origin	Focal spasticity
Onset	Gradual titration over weeks	Short acting, quick peak	Several days to take effect	7–10 days
Side Effects	Drowsiness, fatigue, weakness	Sedation, hypotension, dry mouth	Liver toxicity, muscle weakness	Localized weakness, pain
Use Case	Long-term generalized spasticity	Intermittent or nocturnal use	Adjunctive for refractory cases	Targeted muscle groups

Conclusion

The most appropriate drug of choice for spasticity is not a universal one, but rather a decision tailored to the individual patient's condition, functional goals, and tolerance for side effects. Oral medications like baclofen and tizanidine are often initiated for generalized spasticity, with the choice influenced by the underlying condition and side effect profile. For focal spasticity, botulinum toxin injections offer targeted relief. When oral medications fail or are poorly tolerated, more advanced interventions such as intrathecal baclofen delivery can provide significant relief for severe cases. A multidisciplinary approach involving medication, rehabilitation therapy, and careful monitoring by a healthcare professional is key to effective management.

For more detailed information, consult the National Multiple Sclerosis Society on spasticity medications.

Frequently Asked Questions

Oral baclofen (Lioresal) is often the most commonly prescribed medication for generalized spasticity, particularly for patients with multiple sclerosis or spinal cord injuries.

Studies have shown no significant difference in the overall efficacy of baclofen and tizanidine for reducing spasticity. The choice often depends on the patient's condition and tolerance for side effects, as tizanidine may cause less muscle weakness but more drowsiness in some individuals.

Botulinum toxin is injected directly into specific spastic muscles. It works by blocking the release of acetylcholine, a neurotransmitter that signals muscle contraction, leading to temporary muscle relaxation.

Intrathecal baclofen (ITB) therapy involves surgically implanting a pump under the skin to deliver baclofen directly into the spinal fluid. This method allows for higher concentrations of the drug at the spinal level with fewer systemic side effects, making it suitable for severe, generalized spasticity.

Dantrolene can cause generalized muscle weakness and has a risk of liver toxicity, requiring careful monitoring of liver function.

Diazepam is a benzodiazepine and its use for spasticity is typically limited to short-term management due to its potential for sedation, tolerance, and physical dependence.

Yes, it is common for patients to use a combination of therapies to manage their spasticity effectively. For example, oral medications for generalized symptoms may be combined with botulinum toxin injections for specific, problematic muscles.

ITB therapy is considered for individuals with severe, widespread spasticity who have not responded adequately to oral medications or experience intolerable side effects.