What is the recommended muscle relaxer for neck and scapula pain, as well as mid back pain?

Recommended Muscle Relaxer for Neck, Scapula, and Mid-Back Pain

For neck, scapula, and mid-back pain, cyclobenzaprine 5 mg three times daily is the recommended first-line muscle relaxant, with tizanidine as an alternative if cyclobenzaprine is not tolerated. 1, 2

Primary Recommendation: Cyclobenzaprine

• Cyclobenzaprine is FDA-approved specifically for acute, painful musculoskeletal conditions and should be used as an adjunct to rest and physical therapy 2
• Start with 5 mg three times daily, which has demonstrated statistically significant superiority over placebo for pain relief, medication helpfulness, and global improvement at days 3-4 and day 8 2
• The 5 mg dose provides efficacy comparable to 10 mg but with a more favorable side effect profile 2
• Limit treatment duration to 2-3 weeks maximum, as adequate evidence for longer use is not available and muscle spasm from acute musculoskeletal conditions is generally short-duration 2

Alternative Option: Tizanidine

• Tizanidine is the preferred alternative muscle relaxant based on American College of Physicians recommendations, with demonstrated efficacy in 8 trials for acute low back pain 3, 1
• Start with 2-4 mg and titrate upward as needed 1
• Tizanidine may be particularly useful if cyclobenzaprine causes excessive sedation or if the patient has concurrent radicular symptoms 1
• Monitor for hepatotoxicity, though this is generally reversible 1

Important Clinical Considerations

Efficacy Profile

• Cyclobenzaprine's efficacy is independent of its sedative effects, meaning pain relief occurs regardless of whether drowsiness develops 2, 4
• Both cyclobenzaprine and tizanidine provide short-term pain relief within 2-4 days for acute musculoskeletal pain 3, 1
• Evidence supports muscle relaxants being moderately superior to placebo, with relative risk of 0.80 (CI 0.71-0.89) for not achieving pain relief at 2-4 days 3

Combination Therapy

• Adding a muscle relaxant to NSAIDs or acetaminophen provides consistently greater short-term pain relief than monotherapy 1
• When combining cyclobenzaprine with naproxen, expect more drowsiness but potentially fewer gastrointestinal adverse events 2
• No evidence suggests muscle relaxants enhance the clinical effect of analgesics, but combination therapy is well-tolerated 2

Safety and Adverse Effects

• All skeletal muscle relaxants increase central nervous system adverse events (RR 2.04, CI 1.23-3.37), primarily drowsiness, dizziness, and sedation 3, 1
• Dry mouth occurs more frequently with cyclobenzaprine compared to other muscle relaxants 2
• Serious complications are rare, and most adverse events are self-limited 3, 1
• Assess response within 2-4 days; if no improvement occurs after a time-limited course, reassess the diagnosis and consider alternative therapies 1

Agents to Avoid

• Carisoprodol should be avoided due to growing concerns about abuse potential, despite its efficacy 4
• Benzodiazepines (diazepam, lorazepam) have no direct analgesic effect and carry high risk in terms of falls, dependence, and cognitive impairment 3
• Baclofen and dantrolene have only sparse evidence (2 trials) for musculoskeletal pain and are reserved for spasticity from upper motor neuron syndromes 3, 1

Special Populations

• In patients with mild hepatic impairment, start cyclobenzaprine at 5 mg and titrate slowly upward 2
• Moderate to severe hepatic insufficiency is a contraindication to cyclobenzaprine use 2
• In older adults, muscle relaxants carry increased risk for falls and should be used with particular caution 3

Monitoring Plan

• Evaluate pain relief, muscle spasm reduction, and functional improvement at 2-4 days 1
• Monitor for excessive sedation, dizziness, and dry mouth throughout treatment 1, 2
• If using tizanidine, monitor liver function tests for hepatotoxicity 1
• Discontinue after 2-3 weeks regardless of response, as prolonged use lacks evidence of benefit 2