Objective: To report the etiology of treatable head drop in Parkinson’s disease (PD): one patient from rotigotine patch and the other two from neck extensor myopathy, and discuss the phenomenology and treatment.

Background: Dropped head syndrome (DHS), a non-fixed flexion of cervical spine, can be seen in neuromuscular and movement disorders, especially parkinsonism. The etiologies of DHS in parkinsonism include anterocollis (dystonia of the neck flexors, commonly seen in multiple system atrophy but also PD), medications such as pramipexole and rotigotine, as well as co-existing neuromuscular disorders such as neck extensor myopathy and myasthenia gravis.

Methods: Case report.

Results: We report three patients with PD and DHS. Patient 1 developed DHS soon after rotigotine patch was increased from 2 to 6 mg/day, which gradually improved within a couple of weeks after the discontinuation of rotigotine. The other two patients developed DHS over the course of several weeks. Examination revealed weakness of the neck extensors. Neck extensor myopathy was confirmed on electromyography and muscle biopsy which also disclosed evidence of inflammation in Patient 3. DHS in Patient 3 improved markedly after the treatment with steroids and intravenous immunoglobulin. Videos will be presented.

Conclusions: Rotigotine and inflammatory neck extensor myopathy are treatable causes of DHS in parkinsonism not to miss. It is crucial to recognize these etiologies early, and treat by discontinuing the offending agent or utilizing steroids or immunotherapies to avoid permanent disability. Our case is the second case report of rotigotine-induced DHS in the literature.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/dropped-head-syndrome-in-parkinsonism-two-treatable-etiologies-not-to-miss/