What medications are used to treat myalgia?

Medications for Myalgia

For myalgia, start with NSAIDs (ibuprofen 400 mg) or acetaminophen as first-line therapy, reserving skeletal muscle relaxants for musculoskeletal conditions and considering antidepressants or anticonvulsants only for chronic or neuropathic myalgic pain. 1

First-Line Pharmacologic Options

NSAIDs (Preferred Initial Choice)

• Ibuprofen 400 mg is the safest and most effective NSAID for myalgia, providing anti-inflammatory and analgesic effects through COX-1 and COX-2 inhibition 1, 2
• Higher doses (600-800 mg) may offer slightly greater analgesia but increase adverse effects 2
• Use with caution in patients with cardiovascular disease, chronic renal disease, or history of gastrointestinal bleeding 1
• Topical NSAIDs (diclofenac) can be effective for localized musculoskeletal pain with fewer systemic side effects 1, 3

Acetaminophen (Alternative First-Line)

• Appropriate for mild to moderate myalgia, particularly when NSAIDs are contraindicated 1, 2
• Use up to 1,000 mg per dose, but limit total daily dose to 3-4 grams 1
• Reduce dosing in patients with chronic alcohol use, liver disease, or malnutrition 1
• Less potent than NSAIDs but better tolerated in many patient populations 4, 2

Second-Line Options for Specific Myalgia Types

Skeletal Muscle Relaxants

• Approved for musculoskeletal conditions and spasticity, though most evidence is for acute rather than chronic pain 1
• Cyclobenzaprine has demonstrated benefit specifically for fibromyalgia-related myalgia 1
• Caution: potential for abuse and addiction with some agents 1

For Chronic or Neuropathic Myalgic Pain

Antidepressants:

• Tricyclic antidepressants (TCAs), SNRIs (duloxetine, milnacipran), and SSRIs enhance monoaminergic neurotransmission with strong evidence for analgesic effects 1
• Duloxetine is FDA-approved for fibromyalgia and diabetic neuropathy 1
• Avoid TCAs in older adults (≥65 years) due to anticholinergic effects and cardiovascular side effects (hypertension, postural hypotension, arrhythmias) 1
• Amitriptyline can be tried for myalgic pain, though evidence is limited 1, 5

Anticonvulsants:

• Pregabalin and gabapentin are FDA-approved for fibromyalgia and work by binding calcium channels to inhibit excitatory neurotransmitter release 1
• Can be tried for conditions with myalgic pain 5
• Most bothersome side effects are somnolence, dizziness, and weight gain 1

Topical Analgesics

• Lidocaine, salicylate, and capsaicin can treat localized myalgia 1
• Evidence on topical lidocaine and capsaicin is limited 1

Critical Pitfalls to Avoid

Opioids are NOT recommended for myalgia:

• Insufficient evidence for long-term benefits in chronic pain 1
• High rates of adverse events (50% of patients), with 25% withdrawing due to side effects 1
• Increased risk for opioid use disorder, overdose, all-cause deaths, fractures, falls, and myocardial infarction 1
• Only small, short-term improvements in pain (mean 0.79 on 0-10 scale), with benefits decreasing over time 1

NSAID Safety Considerations:

• Use lowest effective dose for shortest duration needed 1
• In older adults or those with gastrointestinal comorbidities, consider COX-2 inhibitors or NSAIDs with proton pump inhibitors 1
• Monitor for gastritis, peptic ulcer disease, cardiovascular events, and fluid retention 1

Poor Efficacy Agents:

• Codeine, propoxyphene, and tramadol have shown poor efficacy and significant side effects for acute pain 2