Review began 11/06/2023 Review ended 11/13/2023 Published 11/22/2023 © Copyright 2023 Morgom et al. This is an open access article distributed under the terms of the Creative Commons Attribution License CC- BY 4.0., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. A Case of Tizanidine Withdrawal Syndrome: Features and Management in the Emergency Department Marwa Morgom , Doaa M. Sabir , Hanna Elbashir , Leena Saeed , Amal Alamin , Yara Abuazab , Nadir Abdelrahman 1. Emergency Medicine, Hamad General Hospital, Doha, QAT 2. Internal Medicine, Hamad Medical Corporation, Doha, QAT 3. Family Medicine, Michigan State University College of Human Medicine, East Lansing, USA 4. Medicine and Surgery, Jordan University of Science and Technology, Irbid, JOR 5. Family Medicine, Hamad General Hospital, Doha, QAT 6. Family Medicine - Geriatrics, Michigan State University College of Human Medicine, East Lansing, USA Corresponding author: Leena Saeed, leenasaeed95@hotmail.com Abstract Anxiety medications, muscle relaxants, and sleeping pills have the potential to cause complications, side effects, and withdrawal symptoms if not prescribed and managed appropriately. Tizanidine, a short-acting muscle relaxant, acts on central alpha-2-adrenergic receptors to reduce spasticity. However, abrupt withdrawal of tizanidine can lead to symptoms such as hypertension, reflex tachycardia, hypertonicity, and anxiety as a result of high adrenergic activity. Few cases have been reported on tizanidine withdrawal syndrome. Here, we are presenting a rare occurrence of tizanidine withdrawal syndrome in a patient presenting to the emergency department with vomiting, generalized tremor, dysthermia, hypertension, and tachycardia. We discuss the management approach used to stabilize the patient and successfully control the symptoms by reintroducing a low therapeutic dose of tizanidine. Categories: Psychiatry, Emergency Medicine, Substance Use and Addiction Keywords: withdrawal syndrome, alpha 2-adrenoceptor agonists, adrenergic effect, tizanidine withdrawal, tizanidine Introduction Tizanidine is an imidazole derivative with central analgesic action used as a muscle relaxant to treat muscle spasms and chronic spasticity. It has a similar structure to clonidine and strongly binds to α2-agonist and imidazoline (I) receptors [1]. Presynaptic inhibition, by reducing the nervous reflex, has the ability to act as an analgesic [2]. Tizanidine's muscle relaxant effects, which are evident in its suppression of spinal reflexes, are mediated by imidazoline receptors [3]. Tizanidine withdrawal results in a rebound peak in circulating catecholamine levels in the blood, which causes hypertension, tachycardia, and Increased spasticity [4]. However, tizanidine withdrawal syndrome is uncommon, with only a few cases reported in the literature. Sudden discontinuation of tizanidine increases the risk of developing withdrawal syndrome. Therefore, it is advisable to taper off the medication rather than abrupt cessation. We report a case of a 29-year-old male who presented to the emergency department with symptoms of adrenergic overstimulation, which was found to be due to tizanidine withdrawal. Case Presentation This case involves a 29-year-old male patient without any history of drug abuse or chronic disease. He did have a history of insomnia. He had sought treatment from a psychiatrist and was prescribed tizanidine low dose for insomnia. Unfortunately, due to poor follow-up, he continued taking this medication at a significantly higher dose (300 mg daily) than the recommended daily limit of 36 mg. The patient was on tizanidine for seven months. The patient presented to the emergency department with symptoms including vomiting, continuous hiccups, and fever. These symptoms began approximately 10 hours after he missed his last dose of tizanidine, which was unavailable to him at the time. On clinical evaluation, the patient was in acute distress, presenting with a fever of 38°C, blood pressure of 200/150, and a pulse rate of 160 beats per minute. The patient also had a respiratory rate of 25 breaths per minute and maintained saturation on room air. Physical examination revealed an alert and oriented patient with a Glasgow Coma Scale score of 15/15. However, the patient appeared agitated with a flushed face and sweaty palms. Initial investigations showed supraventricular tachycardia (SVT) in the electrocardiogram (ECG) (Figure 1), which later reverted to sinus tachycardia (Figure 2). Routine laboratory tests were conducted, including complete blood count (CBC), renal function test, serum electrolytes, and serum creatine phosphokinase 1 1 1 2 3 4, 5 6 Open Access Case Report DOI: 10.7759/cureus.49248 How to cite this article Morgom M, Sabir D M, Elbashir H, et al. (November 22, 2023) A Case of Tizanidine Withdrawal Syndrome: Features and Management in the Emergency Department. Cureus 15(11): e49248. DOI 10.7759/cureus.49248