Tardive Dystonia Associated With Ziprasidone

Ms. A, a 56-year-old woman, was seen with a chief complaint of involuntary jaw movements. She had a 35-year history of migraines for which she had received a number of treatments (triptans, beta-blockers and calcium channel blockers, antiepileptics, antidepressants, and clonazepam) with limited success. Her first trial with an atypical neuroleptic was 2.5 years before her presentation, when she was administered ziprasidone (80 mg/day). Ms. A experienced a moderate decrease in the frequency and severity of her migraine attacks. Eleven months later, she started noticing mild involuntary movements of her tongue, and ziprasidone was gradually discontinued. Within 2 weeks, involuntary movements involving jaw opening were superimposed on the involuntary movements of her tongue. Gradually, her symptoms intensified, causing eating difficulties accompanied by weight loss (5–6 kg). She also experienced occasional tongue and oral mucosa injuries. Her past medical history was remarkable only for a hysterectomy performed for an ovarian cyst.

A neurological examination revealed frequent, sustained jaw opening, with occasional tongue protrusions and rare dystonic furrowing of her eyebrows. No other abnormalities were noted; brain magnetic resonance imaging was normal. Ms. A had already received botulinum toxin type A injections without success and declined repeat injections.