title: EFNS guidelines on diagnosis and treatment of primary dystonias.
abstract: OBJECTIVE
  to provide a revised version of earlier guidelines published in 2006.
  
  
  BACKGROUND
  primary dystonias are chronic and often disabling conditions with a widespread spectrum mainly in young people.
  
  
  METHODS
  primary dystonias are classified as pure dystonia, dystonia plus or paroxysmal dystonia syndromes. Assessment should be performed using a validated rating scale for dystonia. Genetic testing may be performed after establishing the clinical diagnosis. DYT1 testing is recommended for patients with primary dystonia with limb onset before age 30, and in those with an affected relative with early-onset dystonia. DYT6 testing is recommended in early-onset or familial cases with cranio-cervical dystonia or after exclusion of DYT1. Individuals with early-onset myoclonus should be tested for mutations in the DYT11 gene. If direct sequencing of the DYT11 gene is negative, additional gene dosage is required to improve the proportion of mutations detected. A levodopa trial is warranted in every patient with early-onset primary dystonia without an alternative diagnosis. In patients with idiopathic dystonia, neurophysiological tests can help with describing the pathophysiological mechanisms underlying the disorder.
  
  
  METHODS
  botulinum toxin (BoNT) type A is the first-line treatment for primary cranial (excluding oromandibular) or cervical dystonia; it is also effective on writing dystonia. BoNT/B is not inferior to BoNT/A in cervical dystonia. Pallidal deep brain stimulation (DBS) is considered a good option, particularly for primary generalized or cervical dystonia, after medication or BoNT have failed. DBS is less effective in secondary dystonia. This treatment requires a specialized expertise and a multidisciplinary team.
authors.affiliation: Istituto Neurologico Carlo Besta, Milan, Italy Università Cattolica del Sacro Cuore, Milan, Italy. alberto.albanese@unicatt.it
authors.forename: A
authors.initials: A
authors.lastname: Albanese
authors.forename: F
authors.initials: F
authors.lastname: Asmus
authors.forename: K P
authors.initials: KP
authors.lastname: Bhatia
authors.forename: A E
authors.initials: AE
authors.lastname: Elia
authors.forename: B
authors.initials: B
authors.lastname: Elibol
authors.forename: G
authors.initials: G
authors.lastname: Filippini
authors.forename: T
authors.initials: T
authors.lastname: Gasser
authors.forename: J K
authors.initials: JK
authors.lastname: Krauss
authors.forename: N
authors.initials: N
authors.lastname: Nardocci
authors.forename: A
authors.initials: A
authors.lastname: Newton
authors.forename: J
authors.initials: J
authors.lastname: Valls-Solé
mesh_terms: D001905:Botulinum Toxins / Q000627:therapeutic use*; D046690:Deep Brain Stimulation; D004421:Dystonia / Q000175:diagnosis* / Q000235:genetics / Q000503:physiopathology / Q000628:therapy*; D020821:Dystonic Disorders / Q000175:diagnosis* / Q000235:genetics / Q000503:physiopathology / Q000628:therapy*; D005917:Globus Pallidus / Q000503:physiopathology / Q000601:surgery; D006801:Humans; D018832:Molecular Chaperones / Q000235:genetics
chemical_list: D018832:Molecular Chaperones; C108175:TOR1A protein, human; D001905:Botulinum Toxins; C096326:botulinum toxin type E