There is no single best medication for spasticity. The right choice depends on whether your spasticity is widespread across many muscle groups or concentrated in a few specific areas, what’s causing it, and which side effects you can tolerate. That said, oral baclofen is the most widely prescribed first-line option for generalized spasticity in adults, and it’s typically the starting point before other medications are considered.
Why No One Drug Works for Everyone
Spasticity has many causes: multiple sclerosis, spinal cord injury, stroke, cerebral palsy, and traumatic brain injury among them. Each condition creates a different pattern of tight, overactive muscles. A person with spasticity in both legs after a spinal cord injury has very different treatment needs than someone with a stiff hand and forearm after a stroke. Medications also carry distinct trade-offs. Some cause drowsiness, others cause muscle weakness throughout the body, and one carries a risk of liver damage. Finding the best fit often means trying a medication at a low dose, increasing gradually, and switching if the side effects outweigh the benefit.
Baclofen: The Most Common Starting Point
Baclofen works in the brain and spinal cord to calm the overactive nerve signals that keep muscles contracted. It is typically started at 5 mg three times a day, with the dose increased every three days until spasticity improves. Most people end up on 40 to 80 mg per day, and the maximum is 80 mg daily.
The main downsides are drowsiness, fatigue, and a general feeling of muscle looseness that can make you feel weaker. These effects tend to be dose-dependent, meaning they get more noticeable as the dose climbs. Baclofen is generally not recommended for older adults because the sedation can be significant. One important caution: stopping baclofen suddenly after taking it regularly can cause serious withdrawal symptoms, including seizures. Doses should always be tapered gradually.
Tizanidine: An Alternative With a Different Profile
Tizanidine works through a different mechanism, reducing nerve activity in the spinal cord that drives muscle tightness. In a head-to-head trial of people with multiple sclerosis, neurologists and physiotherapists rated baclofen as superior overall for both efficacy and tolerability. Patients themselves rated baclofen’s efficacy as “good to excellent” 39% of the time compared with 24% for tizanidine, though this gap wasn’t statistically significant.
Tizanidine’s most common side effects are drowsiness and dry mouth, both of which occurred more often than with baclofen in that trial. It can also cause low blood pressure and, rarely, hallucinations. One advantage: the muscle weakness that accompanies most oral spasticity drugs tends to be less of a problem with tizanidine, which can matter if you rely on some degree of muscle tone to stand or walk.
Dantrolene: Works Directly on Muscles
Every other oral spasticity medication acts on the brain or spinal cord. Dantrolene is different. It works directly inside muscle cells by blocking the release of calcium that triggers contraction. This makes it useful when central nervous system side effects like drowsiness are a major concern, but it introduces a different risk: liver damage. Liver function tests need to be monitored closely after starting dantrolene, and the medication should be stopped at the first sign of toxicity.
Because dantrolene doesn’t target specific muscles, it can cause generalized weakness throughout the body. This is a significant drawback for anyone who needs some muscle strength preserved for daily activities. It tends to be reserved for people with severe spasticity who haven’t responded well to baclofen or tizanidine, or for those whose spasticity doesn’t need to coexist with functional movement.
Diazepam: Best Suited for Short-Term or Nighttime Use
Diazepam, a benzodiazepine, is effective at reducing spasticity but carries substantial sedation. That sedative quality actually makes it useful for one specific scenario: nighttime spasticity and painful spasms that disrupt sleep. Doses for muscle spasms in adults range from 2 mg to 15 mg per day, and can go up to 20 mg three times daily in more severe cases.
The American Academy of Neurology recommends diazepam for short-term spasticity treatment, with caution about its side effects. Long-term use brings risks of tolerance (needing higher doses for the same effect), dependence, and cognitive dulling. For these reasons, diazepam is rarely used as the sole long-term spasticity medication. It’s more often added at bedtime or used for brief flare-ups.
Botulinum Toxin Injections for Targeted Spasticity
When spasticity is concentrated in specific muscles, such as a clenched fist after a stroke or tight calf muscles causing toe-walking, injections of botulinum toxin directly into those muscles can be more effective than oral medications. The key advantage is precision: the treatment weakens only the injected muscles, avoiding the generalized drowsiness and whole-body weakness that oral drugs cause.
The effects typically become noticeable within a week or two and are assessed at a follow-up appointment roughly 3 to 17 weeks after injection. The effect gradually wears off, and most people return for repeat injections every 4 to 6 months. Botulinum toxin is often used alongside an oral medication, with the injections handling the worst focal tightness and the pill managing background tone elsewhere.
Cannabis-Based Spray for MS Spasticity
A mouth spray containing a combination of THC and CBD (sold as nabiximols in many countries) is approved in some regions specifically for multiple sclerosis spasticity that hasn’t responded to other treatments. In a large real-world study of over 900 patients with resistant spasticity, about 77% experienced at least a 20% improvement in their spasticity scores after four weeks. Among those who continued treatment, spasticity scores dropped by roughly 34% at 18 months, and over 60% achieved a clinically meaningful improvement of 30% or more.
This option is typically reserved for people who have already tried and failed standard oral medications. Availability varies by country, and it’s not approved in all markets.
Gabapentin: Helpful When Pain Overlaps
Gabapentin is not a first-line spasticity drug, but it plays a useful role when spasticity comes with significant nerve pain, which is common in spinal cord injuries. At lower doses (around 1,200 mg per day), the effects on spasticity can be modest and sometimes only detectable on testing rather than noticeable day to day. At higher doses, up to 3,600 mg per day, clinical improvements become more apparent. The main side effects are drowsiness and unsteadiness. Gabapentin is most often added to another spasticity medication rather than used alone.
Intrathecal Baclofen Pumps for Severe Cases
For people with severe, widespread spasticity that oral medications can’t control, or who experience intolerable side effects from oral baclofen, a surgically implanted pump can deliver tiny amounts of baclofen directly into the fluid surrounding the spinal cord. Because the drug goes straight to where it’s needed, the required dose is a fraction of what’s taken by mouth, and systemic side effects like drowsiness drop dramatically.
Candidates generally need to have already failed oral drug therapy. Before implantation, a test dose of baclofen is injected via lumbar puncture to confirm the person responds. A good response means at least a 2-point drop on standardized spasticity scales lasting 4 to 8 hours. If there’s no response to the test dose, the pump isn’t implanted. The pump requires refills every few months and occasional surgical replacement of the device itself, so it’s a long-term commitment.
Choosing Between Medications
In practice, the decision usually follows a pattern. For generalized spasticity, most clinicians start with baclofen or tizanidine. Baclofen tends to be tried first because it has the longest track record and slightly better efficacy ratings, but tizanidine may be preferred if preserving muscle strength matters more than maximizing spasticity reduction. Dantrolene is considered when the first two options fail or when sedation is unacceptable. Diazepam fills a niche for nighttime spasms and short-term flares.
For focal spasticity, botulinum toxin injections are often the better choice because they avoid systemic side effects entirely. And for MS-related spasticity that resists everything else, the THC/CBD spray offers a meaningful add-on option. Many people with moderate to severe spasticity end up on a combination: an oral medication for baseline control, injections for the most problematic muscles, and sometimes a second oral agent targeting pain or nighttime symptoms.