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Botulinum toxin (BoNT) injections are an effective\ud treatment for cervical dystonia. Approximately\ud 20% of patients eventually stop BoNT treatment,\ud mostly because of treatment failure. These\ud recommendations review the different\ud therapeutic interventions for optimising the\ud treatment in secondary poor responder patients.\ud Immunoresistance has become less common over\ud the years, but the diagnosis has to be addressed\ud with a frontalis test or an Extensor Digitorum\ud Brevis test. In case of immunoresistance to BoNTA,\ud we discuss the place the different therapeutic\ud options (BoNT-A holidays, BoNT-B injections,\ud alternative BoNT-A injections, deep brain\ud stimulation). When poor responders are not\ud immunoresistant, they benefit from reviewing (1)\ud injections technique with electromyography or\ud ultrasound guidance, (2) muscles selection and\ud (3) dose of BoNT. In addition, in both scenarios,\ud a holistic approach including drug treatment,\ud retraining and psychological support is valuable\ud in the management of these complex and severe\ud cervical dystonia.