What are the recommended treatments for muscle spasms?

Treatment Options for Muscle Spasms

For muscle spasms, first-line treatments include cyclobenzaprine for acute musculoskeletal conditions, baclofen for severe spasticity, and benzodiazepines when anxiety and muscle spasm coexist. 1

First-Line Pharmacological Options

• Cyclobenzaprine (10-30 mg/day) is recommended as an adjunct to rest and physical therapy for relief of muscle spasm associated with acute, painful musculoskeletal conditions, but only for short periods (up to 2-3 weeks) 1, 2
• Baclofen (starting at 10 mg/day with weekly increases up to 30 mg/day) is effective as a second-line drug for muscle spasm, particularly in patients with severe spasticity resulting from central nervous system injury or for muscle cramps associated with cirrhosis 3, 1
• Benzodiazepines such as diazepam may be justified for management of muscle spasm, especially in situations where anxiety, muscle spasm, and pain coexist 3, 4
• Tizanidine has shown efficacy for acute low back pain and can be considered as an alternative first-line agent, especially for chronic conditions with spasticity 3, 1

Medication Considerations and Cautions

• Cyclobenzaprine is structurally similar to tricyclic antidepressants with similar potential adverse effects including sedation and anticholinergic effects 3, 2
• Carisoprodol should be avoided due to concerns about drug abuse potential and has been removed from the European market 3, 1
• Muscle relaxants should generally be avoided in elderly patients due to increased risk of falls, sedation, and anticholinergic effects 3, 1
• Benzodiazepines are associated with a higher total number of adverse events (particularly drowsiness and dizziness) compared with placebo 3, 5
• Never abruptly discontinue muscle relaxants after prolonged use; implement a slow tapering period to prevent withdrawal symptoms, particularly with baclofen 3, 1

Specific Clinical Scenarios

• For muscle spasms associated with cirrhosis: baclofen (10 mg/day, with weekly increases up to 30 mg/day) or albumin infusion are recommended 3, 1
• For acute low back pain with muscle spasm: skeletal muscle relaxants have been found moderately superior to placebo for short-term pain relief 3
• For neuropathic pain with muscle spasm: gabapentin or topiramate may provide benefit 3
• For pyridoxine deficiency-related muscle spasms (rare): pyridoxine supplementation should be considered, particularly in patients with diabetes 6

Non-Pharmacological Approaches

• Rest and activity modification are recommended for acute muscle spasms 1
• Stretching, massaging the affected muscles, and application of ice should accompany drug therapy 1
• Rhythmic movement strategies can help normalize muscle activity for functional tremors or spasms 1
• Postural alignment training can help normalize movement patterns and muscle activity 1

Monitoring and Follow-up

• During treatment with muscle relaxants, patients should be monitored for adverse effects, particularly central nervous system effects such as drowsiness, dizziness, and cognitive impairment 3, 5
• For patients with neuromuscular disease requiring muscle relaxants, monitoring of neuromuscular blockade is recommended 3
• Assess effectiveness of treatment regularly and discontinue if no benefit is observed after a reasonable trial period 1

Important Caveats

• Evidence for long-term use of muscle relaxants is limited, and they should generally be used for short durations 3, 4
• Benzodiazepines have not shown definitive evidence of direct analgesic properties in most clinical circumstances 7
• Muscle relaxants may be ineffective for certain types of muscle spasms, such as those related to specific vitamin deficiencies 6
• Combination therapy with multiple agents should be approached cautiously due to increased risk of adverse effects 1