What is the best treatment for nocturnal muscle cramps?

Treatment of Nocturnal Muscle Cramps

Start with baclofen 10 mg/day, titrating weekly by 10 mg increments up to 30 mg/day for severe nocturnal muscle cramps, as this is the only medication with consistent guideline support for efficacy. 1, 2

First-Line Treatment Approach

Non-pharmacological interventions should be attempted initially, including stretching the affected muscle during the cramp, massage, and ice application, though evidence for prophylactic stretching is conflicting. 1, 3 While one uncontrolled study suggested benefit from calf-stretching exercises, a randomized controlled trial found no significant reduction in cramp frequency or severity with regular stretching programs. 3

Pharmacological Management

Baclofen (Primary Recommendation)

For patients with severe, frequent nocturnal cramps, baclofen is the recommended pharmacological treatment:

• Start at 10 mg/day (or 5 mg three times daily in older adults) 1, 2
• Titrate weekly by 10 mg/day up to a maximum of 30 mg/day 1, 2
• Monitor for dizziness, somnolence, cognitive impairment, muscle weakness, urinary dysfunction, and orthostatic hypotension 2
• Never discontinue abruptly after prolonged use—taper slowly to prevent withdrawal symptoms including CNS irritability 2

Magnesium Supplementation (Limited Evidence)

If considering magnesium oxide, the evidence is weak but suggests:

• Dose: 400-500 mg daily (though prior studies used 1,000-1,500 mg daily) 1
• Contraindicated in renal insufficiency due to risk of toxic accumulation 1
• Correcting documented hypomagnesemia (12-24 mmol or 480-960 mg daily at night) is different from supplementation in normomagnesemic patients 1
• Always correct water and sodium depletion first, as secondary hyperaldosteronism worsens magnesium losses 1

Quinine (No Longer Recommended)

Quinine should not be used for routine treatment of nocturnal leg cramps despite being the only medication proven to reduce cramp frequency. 4, 5 The risks outweigh benefits:

• Only modest benefit in reducing cramp frequency and intensity 5
• Risk of rare but serious immune-mediated reactions 5
• Dose-related side effects, particularly in older adults 5
• If used at all, restrict to severe symptoms with regular review and informed patient discussion 5
• A randomized trial showed that 26.5% more patients successfully stopped quinine without worsening symptoms when advised to discontinue 3

Identify and Address Underlying Causes

Medication Review

Discontinue or substitute medications strongly associated with leg cramps: 4

• Intravenous iron sucrose
• Conjugated estrogens
• Raloxifene
• Naproxen
• Teriparatide
• Diuretics (particularly in cirrhosis patients with incapacitating cramps) 2, 5
• Long-acting beta-agonists 5

Electrolyte Correction

Check and correct documented electrolyte abnormalities, particularly hypokalemia and hypomagnesemia, though routine supplementation in normomagnesemic patients lacks evidence. 2 For athletes exercising in heat with cramps lasting >1 hour, increase sodium intake to 1.5 g/L of fluid. 6

Neurological Assessment

Nocturnal leg cramps are associated with markers of neurological dysfunction: 7

• Muscle twitching (OR 4.6)
• Lower limb tingling (OR 4.1)
• Foot dorsiflexion weakness (OR 1.02)

Consider evaluation for lumbar canal stenosis, peripheral neuropathy, or other neurological conditions if these features are present. 7, 4

Differential Diagnosis Considerations

Distinguish nocturnal leg cramps from mimicking conditions through careful history: 6, 4

• Restless legs syndrome: Urge to move legs, worse in evening, relieved by movement, returns after sitting/lying down 6
• Claudication: Pain with walking, relieved by rest 4
• Myositis: Persistent muscle pain and weakness 4
• Peripheral neuropathy: Numbness, weakness, sensory changes 6, 4

Special Populations

Older Adults

• Start baclofen at 5 mg three times daily (maximum 15 mg/day initially) with careful monitoring 2
• Higher risk of falls with muscle relaxants like cyclobenzaprine 2
• Avoid benzodiazepines due to high-risk profile 2

Patients with Cirrhosis

• Baclofen 10-30 mg/day is particularly effective 2
• Consider albumin infusion 20-40 g/week 2
• Discontinue diuretics if cramps are incapacitating 2

Pregnancy

• Associated with increased cramp frequency 4
• Avoid quinine and most pharmacological agents 4

Common Pitfalls

• Do not prescribe cyclobenzaprine or methocarbamol believing they directly relieve muscle spasm—their effects are nonspecific and not related to muscle relaxation 2
• Do not routinely order laboratory testing—history and physical examination are usually sufficient unless specific underlying conditions are suspected 4
• Do not use quinine as first-line therapy given the unfavorable risk-benefit profile 4, 5
• Do not supplement magnesium in patients with renal insufficiency without careful monitoring 1