What are the treatments for muscle cramps?

Treatment of Muscle Cramps

For acute muscle cramps, immediately rest and discontinue the triggering activity, then stretch and massage the affected muscle, with ice application as needed; for prevention and chronic management, stretching exercises are the primary non-pharmacological intervention, while baclofen (10-30 mg/day) is the most effective pharmacological option for severe cases. 1

Immediate Management of Acute Cramps

When a muscle cramp occurs, the following steps should be taken immediately:

• Stop the activity that triggered the cramp and rest 1
• Stretch the affected muscle actively and hold the stretch 1
• Massage the cramping muscle to help relieve the spasm 1, 2
• Apply ice directly to the cramping muscle 1
• For heat-related cramps specifically, cool off and drink electrolyte-carbohydrate mixtures 1

These interventions work by interrupting the involuntary muscle contraction and addressing immediate physiological triggers. Patient surveys confirm that massage, stretching, and walking are among the most commonly used and helpful non-pharmacological treatments 2.

Preventive Strategies

Stretching Programs

Daily stretching is the cornerstone of cramp prevention, though the evidence quality varies by protocol:

• Combined calf and hamstring stretching for 6 weeks may reduce cramp severity (reducing pain by 1.3 cm on a 10 cm scale) in adults over 55 years old, though the effect on frequency is uncertain 3
• Calf stretching alone for 12 weeks may make little to no difference in cramp frequency 3
• The evidence for combined calf, quadriceps, and hamstring stretching in younger adults (50-60 years) with metabolic syndrome is very uncertain 3

Addressing Underlying Causes

Correct electrolyte abnormalities, particularly hypokalemia and hypomagnesemia, as these are common triggers 1:

• Electrolyte imbalances, especially sodium, potassium, and magnesium deficiencies, can trigger cramps during or after exercise 4
• Dehydration from inadequate fluid intake contributes to cramping, particularly in hot environments 4
• Heavy sweaters who lose more sodium are at higher risk 4

Review medications that may cause cramps as a side effect, particularly diuretics like hydrochlorothiazide 4, as well as lipid-lowering agents, antihypertensives, beta-agonists, insulin, oral contraceptives, and alcohol 5.

Pharmacological Treatment for Severe or Refractory Cramps

First-Line Pharmacological Option

Baclofen is the preferred medication for severe muscle cramps 1:

• Start at 10 mg/day 1
• Increase by 10 mg/day weekly up to 30 mg/day 1
• Particularly effective in patients with liver disease 1
• Monitor serum creatinine, sodium, and potassium during treatment, especially in the first month in cirrhotic patients 1

Alternative Pharmacological Options

For patients who cannot tolerate or do not respond to baclofen:

• Orphenadrine has been proposed, particularly for patients with cirrhosis 1
• Methocarbamol can be considered for skeletal muscle pain, though effects are nonspecific 1
• Human albumin (20-40 g/week) may benefit patients with liver disease 1
• Vitamin B complex, Naftidrofuryl, and calcium channel blockers (such as diltiazem) are possibly effective and may be considered 6

Medications to Avoid or Use with Extreme Caution

Quinine sulfate should be avoided for routine use despite being effective 6:

• While Class I studies show efficacy, the benefit is modest 6
• The FDA issued an advisory in 2006 warning against off-label use due to potential toxicity 6
• May be considered only in highly select patients for an individual therapeutic trial after discussing potential side effects 6

Important Caveats and Common Pitfalls

Do not prescribe cyclobenzaprine or other muscle relaxants with the mistaken belief that they directly relieve muscle spasm 1:

• Cyclobenzaprine is not specifically indicated for muscle cramps 7
• It does not directly relax skeletal muscle 7
• It has no evidence of efficacy in chronic pain 7
• Common adverse effects include drowsiness, dry mouth, dizziness, and anticholinergic effects 7

Benzodiazepines have limited efficacy for persistent pain and carry high risk profiles, especially in older adults 1.

Be cautious with over-the-counter analgesics, as they are commonly used by patients but carry potential risks 2:

• Nearly one-third of patients with leg cramps may be at risk of medication adverse events from over-the-counter analgesics 2
• Many patients seek treatment information from the Internet (30.8% in one survey), which could lead to inappropriate self-treatment 2

Special Populations

For patients with liver disease or cirrhosis:

• Baclofen (10-30 mg/day) is particularly recommended 1
• Human albumin (20-40 g/week) has shown efficacy 1
• Close monitoring of electrolytes and renal function is essential 1

For exercise-associated muscle cramps:

• Focus on preventing premature fatigue through appropriate nutrition and adequate training 5
• Address heat exposure and heavy sweating, which increase sodium losses 4
• Ensure adequate hydration with electrolyte-carbohydrate mixtures during prolonged exercise (>1 hour) 4