If you have been taking a Parkinson’s medication that contains levodopa for some time, you may develop some movement difficulties throughout the day, or find your symptoms get worse as the effects of your medication start wearing off.
These ‘off periods’ tend to happen more frequently as Parkinson’s progresses. They are caused by the brain losing more and more of the cells that produce the chemical dopamine, so your body becomes increasingly dependent on the availability of Parkinson’s medicine to provide it with dopamine.
It can become increasingly hard to predict when your medication will be effective, and you might experience ‘on/off’ periods of fluctuation:
- feeling ‘on’ and in control of your symptoms after your most recent dose of levodopa
- then experiencing ‘off’ periods as your medication wears off, and symptoms re-emerge. This can happen in the morning time when you wake or at intermittent times during the day.
Wearing off and motor fluctuations can occur any time after starting to take levodopa, although it more commonly develops after four to five years of levodopa treatment.
However, the more Parkinson’s medications added to the treatment regime, the higher the incidence of motor fluctuations. For example when a dopamine agonist medication is added to levodopa.
How is wearing off diagnosed in Parkinson’s?
If you notice a change in your usual symptom pattern, you should discuss this with your doctor because you may be experiencing wearing off. Your doctor will then be able to adjust your medication regime to provide better symptom control, possibly by reducing the interval between the levodopa doses and increasing the number of daily doses.
What are the signs and symptoms of ‘wearing off’ in Parkinson’s?
Wearing off symptoms are very individual. In some people, re-emergence of motor symptoms such as tremor may be the first sign. For others it might be stiffness and difficulty initiating movement, freezing of gait.
But wearing off symptoms may not be related to movement at all. They may be experienced in the form of non-motor symptoms such as increased anxiety, restlessness, low mood, fear, a peculiar feeling in the stomach, numbness or tingling in the fingers, sweating and fatigue.
What are motor fluctuations?
Motor fluctuations are the changes in motor performance. They are associated generally with taking levodopa, but also with dopamine agonists in some cases (although this is less common). The three main issues related to motor fluctuations are ON / OFF phenomenon, dyskinesia and dystonia. These fluctuations tend to be more prevalent in those with young-onset Parkinson’s but they can experienced at any age.
The main factor leading to the development of motor fluctuations is the gradual loss of dopamine-producing (dopaminergic) cells that happens over time in people with Parkinson’s.
This means that the level of dopamine in your brain is increasingly dependent on the availability of levodopa in the blood, which in turn relies on your most recent dose of medication.
What symptoms will I experience with motor fluctuations?
Wearing off is usually the first sign that medication is no longer working effectively. The symptoms of motor fluctuations include:
‘On-off’ phenomenon
Experiencing sudden changes in movement control, which can last for a variable period of time. These fluctuations are called the ‘on-off’ phenomenon:
- ‘On’ time is when levodopa is working well and your symptoms are controlled.
- ‘Off’ time is when levodopa is no longer working well and symptoms such as tremor, rigidity and slow movement re-emerge.
As Parkinson’s progresses the ‘on-off’ swings become less closely related to the timing of a dose of levodopa. Instead it is thought that the ‘on-off’ phenomenon is related to other processes in the brain, although these mechanisms are unclear.
Delayed ‘on’
Experiencing a delay in medication taking effect. Levodopa usually starts to take effect after 20-30 minutes. Delays in effect usually occur related to slow gastric emptying, levodopa taken with food, or not drinking enough fluid with the medication to wash it through the stomach to get to the bowel to be absorbed. A controlled-release preparation of levodopa will take longer to take effect but has a longer-lasting effect.
Dyskinesia (diphasic dyskinesia) – involuntary movements
Dyskinesia is the term used to describe unintended, involuntary and uncontrollable movements. These include dance-like movements with twitches, jerking, twisting or simple restlessness. This is different to tremor, as tremor is rhythmic and dyskinesia is not. Many parts of the body can be affected including the upper and lower limbs, head, neck, mouth and trunk.
Dyskinesia affects each person differently both in its timing, frequency and severity. It generally occurs when levodopa and other dopaminergic medications are at their most effective known as peak-dose dyskinesia. Less commonly, dyskinesia can also occur when levodopa is just starting to take effect or when it is wearing off – this is known as ‘diphasic dyskinesia’.
Dystonia
It is thought that reduced dopamine levels can cause the signals the brain sends to the muscles to become irregular. This causes dystonia, whereby opposing muscles contract simultaneously and repeatedly over a prolonged period, leading to painful and abnormal postures, involuntary twisting and problems controlling movement. This can affect a part or all of the body. It may last for a short period or most of the day.
Dystonia is often, but not always, linked to the timing of the levodopa.
- ‘Off-dystonia’ can occur when the medication has worn off in effect. This is particularly common in the morning (before the initial morning levodopa dose). This can make it difficult to get out of bed until the next dose of medication starts to take effect. A rapid-acting dispersible form of levodopa can provide quick relief in this situation.
- ‘On-dystonia’ can also occur when levodopa is at its highest level (peak dose) in the bloodstream and dopamine levels are highest in the brain. This high level of dopamine seems to over-stimulate the muscles and cause spasms.
Wearing off and motor fluctuations treatments
Treatment of “off periods” and motor symptom fluctuations can include:
- Keeping a motor diary to help your doctor understand how effective your medications are. Record things like the times of day you have good symptom control, when during each day your symptoms reoccur, and if any foods affect your symptom control
- Adjusting your levodopa medication in dose, frequency or timing (always under supervision of your doctor).
- Addition or discontinuation of some other Parkinson’s medications for example a COMT Inhibitor.
- Commencement of pump / device aided therapies for example Apomorphine, Foslevodopa or Levodopa/ Carbidopa and Levodopa/Carbidopa/Entacapone intestinal Gel
- Deep Brain Stimulation (DBS)
- A dietitian may suggest dietary changes as food can affect how quickly your levodopa is absorbed into your bloodstream
- Adjusting your daily routine to make the most of “on” periods
- Exercise like swimming or walking may help
- Getting enough sleep
- Using complementary therapies like yoga and tai chi to manage stress levels
- Coping strategies to help with specific difficulties during “off” periods.
If you think you are starting to experience wearing off or motor fluctuations, you should discuss this with your doctor promptly so that your medication can be adjusted to minimise your symptoms. Tell them how long your medication is lasting and what happens when it wears off. Remember to tell them about motor and non-motor symptoms.
Keeping a diary
You can help your doctor understand how effective your medications are by keeping a diary. Typically a ‘wearing off diary’, will include details such as:
- the times of day when you take your Parkinson’s medication
- the times of day when you have good symptom control
- which symptoms re-emerge during the day and when
- what symptoms you experience at night
- any other complications you may experience, such as dyskinesia, and their relation to when you take your medication.
It can also be useful to note the timing of meals, drinks and snacks. Make a note of whether eating certain foods affects your symptom control. Protein, for example, can interfere with the absorption of some medications.
By referring to your diary, you and your doctor will be able to more easily see if there is a link between your symptoms and medications and if your medicines need adjusting.
Medication via device-aided therapies
Motor fluctuations can be tricky to treat, as reducing your dose of levodopa may mean decreased fluctuations, but can also result in other symptoms returning. You will need to work closely with your doctor or Parkinson’s nurse specialist to get the right balance, and generally try to avoid peaks and troughs of levodopa in your bloodstream.
Additionally, apomorphine (a type of dopamine agonist in liquid form) is often used when pills or capsules no longer work well enough to control Parkinson’s symptoms on their own. It can be used alone as a pump infusion or pen injection.
If the motor fluctuations are very troublesome and your symptoms do not respond well to medication, your doctor may consider an assessment for Deep Brain Stimulation (DBS) surgery. This is not suitable for everyone but in some people it can improve movement control.
Other therapies
Your doctor may refer you to a physiotherapist or an occupational therapist. Which therapist you are referred to will depend on the country you live in, the resources available and your individual needs.
- A physiotherapist can help in teaching you techniques to deal with motor fluctuation and wearing off and to improve movement, including balance, gait, posture and transfers.
- An occupational therapist will help you retain as much independence as possible in spite of your movement difficulties. They can assess your home and daily routine and can advise on adaptations at home to make movement as easy and safe as possible.
What can I do at home to relieve wearing off and motor fluctuations?
Diet
For some people eating protein (such as meat, fish, eggs, cheese and beans) can cause problems by reducing gastric emptying or slowing down the amount of levodopa that is absorbed into the bloodstream.
Protein is needed by the body, so it is vital not to stop eating it. However, you may find it helpful to take your medication at least 30-60 minutes before you eat, to allow the medication time to start working.
Some people find it useful to reduce the amount of protein they eat during the day, so that medication is more effective when it’s needed most, and then eat all their daily protein in one meal at the end of the day.
However, these options are not suitable for everyone. You must talk with your doctor before altering your diet or changing the timing of your medication. They can also refer you to a dietitian.
Constipation, a common Parkinson’s symptom, can also affect how well the body absorbs medication, making it less effective.
Making the most of ‘on’ time
If you experience wearing off, it is important that your medication regime is well-managed so you get the most of your ‘on’ time.
This becomes more complicated if you also begin to have dyskinesia. You might then have to decide on a compromise between more ‘on’ time with involuntary movements, or more ‘off’ time with other symptoms. Everyone is different, and you should discuss your options with your doctor or specialist.
Exercise and rest
Exercise such as swimming or walking may help, and getting plenty of sleep is important. If you find daily activities difficult when you are ‘off’ then try to time these around your ‘on’ time so that they are easier.
Managing stress
Stress can worsen motor fluctuations, especially dyskinesia, so try to find time to relax. Trying to do things when you are ‘off’ can be frustrating, so try to time activities for when medication is working well.
Complementary therapies such as yoga or Tai Chi can help with relaxation, or you may find a massage helpful.
References and acknowledgements
We would like to thank the following:
- Dr Annamária Takáts (Medical Advisor, Delta Hungarian Parkinson Association, Budapest) for her help in reviewing an earlier version of this information
- Parkinson’s UK for permission to use the following source(s) in compiling this information: Dyskinesia (involuntary movements) and wearing off
- Brian Magennis, Advanced Nurse Practitioner and Adjunct Lecturer / Assistant Professor UCD, Mater Misericordiae Hospital, Ireland for reviewing this information
Content last reviewed: July 2026
