Objective: We present a series of three patients with Parkinson’s disease who developed dropped head syndrome (DHS) associated with dopamine agonist therapy, highlighting a potentially reversible cause of axial postural abnormality.

Background: DHS is an abnormal forward flexion of the neck caused by an imbalance in neck muscle tone, resulting in the flexors overpowering the extensors. There is a broad range of possible etiologies, including neuromuscular disease, cervical spondylosis, dystonia associated with parkinsonism, as well as induced by dopamine agonists(1). The postural deformity caused by DHS can be debilitating and impact quality of life.

Method: Case series

Results: Three patients with Parkinson’s disease (ages 75-87 years) developed new or markedly worsening DHS following the initiation of dopamine agonists (two pramipexole, one ropinirole). One patient had mild preexisting anterocollis that progressed after starting pramipexole. Another patient developed severe DHS after starting ropinirole. The third patient had persistent DHS, which was suspected to be related to pramipexole use, but the patient was unable to discontinue the medication due to worsening balance during the prior taper attempts. Neurologic examination demonstrated severe anterocollis in all patients, with associated torticollis in some cases. Imaging did not reveal structural abnormalities sufficient to explain the severity of the deformity. Two patients experienced dramatic improvement in head posture within two months of dopamine agonist discontinuation, although residual cervical dystonia persisted in one case and will be treated with botulinum toxin. One patient had persistent DHS due to the inability to withdraw the medication.

Conclusion: Axial postural abnormalities, such as DHS in Parkinson’s disease, may represent an adverse effect of medication rather than disease progression. Recognizing dopamine agonists as a potential etiology of DHS is important, as the symptoms may improve with medication adjustment. Early recognition may prevent unnecessary diagnostic evaluation and allow for targeted treatment of residual dystonia.

References: 1. Fujimoto K. Dropped head in Parkinson’s disease. J Neurol. 2006;253 Suppl 7:VII21-VII26. doi:10.1007/s00415-006-7006-3

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MDS Abstracts - https://www.mdsabstracts.org/abstract/dopamine-agonist-associated-dropped-head-syndrome-in-parkinsons-disease-a-case-series/