What muscle relaxers, such as metaxalone (Skelaxin) or cyclobenzaprine (Flexeril), can be used to treat migraines?

Muscle Relaxers Are Not Recommended for Migraine Treatment

Muscle relaxers such as metaxalone (Skelaxin) and cyclobenzaprine (Flexeril) are not recommended for migraine treatment as they are not supported by current clinical guidelines and FDA indications. 1, 2

Evidence Against Muscle Relaxers for Migraines

• Metaxalone is FDA-indicated only as an adjunct for acute, painful musculoskeletal conditions, not for migraine headaches 1
• Cyclobenzaprine is specifically indicated for relief of muscle spasm of local origin, not for central nervous system conditions like migraine 2
• Neither medication appears in any of the current migraine treatment guidelines 3, 4
• The 2023 VA/DoD Clinical Practice Guideline for Headache Management does not include muscle relaxants in any of its recommendations for migraine treatment 3

Recommended First-Line Treatments for Acute Migraine

Non-prescription options:

• NSAIDs are recommended as first-line therapy for mild to moderate migraines 3, 4:
  • Ibuprofen (400-800 mg)
  • Naproxen sodium (275-550 mg)
  • Aspirin (650-1000 mg)
• Acetaminophen (1000 mg) for those intolerant to NSAIDs 3
• Combination of aspirin-acetaminophen-caffeine has strong recommendation ("strong for") 3, 4

Prescription options (for moderate to severe migraines):

• Triptans have the strongest evidence for effectiveness 3, 5:
  • Eletriptan, frovatriptan, rizatriptan, sumatriptan (oral or subcutaneous), zolmitriptan (oral or intranasal) - "strong for" recommendation 3
  • Combination of sumatriptan and naproxen - "strong for" recommendation 3
• Newer options with "weak for" recommendations 3:
  • Rimegepant or ubrogepant (gepants)

Preventive Medications for Migraine

If the patient requires preventive therapy due to frequent migraines, the guidelines recommend:

• Strong recommendations for 3, 4:

  • CGRP antagonists (erenumab, fremanezumab, galcanezumab)

• Weak recommendations for 3, 4:

  • Oral magnesium (500-600 mg daily)
  • Topiramate
  • Propranolol
  • Valproate
  • Lisinopril
  • Memantine
  • Atogepant
  • OnabotulinumtoxinA (for chronic migraine only)

Important Clinical Considerations

• Muscle relaxers may cause sedation and other side effects without providing specific benefit for migraine pathophysiology 1, 2
• Overuse of acute medications (including inappropriate use of muscle relaxers) can lead to medication overuse headache 3
• The pathophysiology of migraine involves disruption of pain modulating systems and vascular networks, not primarily muscle tension 6
• Triptans have significantly higher effectiveness (mean OR 4.8) compared to other medication classes in real-world data from millions of migraine attacks 5

Treatment Algorithm

1. For mild to moderate attacks:

   • Start with NSAIDs or acetaminophen
   • Consider combination with caffeine for enhanced effectiveness

2. For moderate to severe attacks or those not responding to step 1:

   • Prescribe a triptan (eletriptan, sumatriptan, or rizatriptan)
   • Consider combination therapy (triptan + NSAID)

3. For frequent migraines requiring prevention:

   • Consider CGRP antagonists as first-line
   • Alternative options include topiramate, propranolol, or magnesium

4. For nausea/vomiting during attacks:

   • Add an antiemetic such as metoclopramide or domperidone 3

Muscle relaxers should not be included in any step of migraine management as they lack evidence of benefit and are not indicated for this purpose.