What is the recommended treatment for muscular pain in the neck and upper back?

Treatment for Muscular Pain in Neck and Upper Back

For muscular pain in the neck and upper back, start with NSAIDs (such as ibuprofen or naproxen) as first-line pharmacologic treatment, with acetaminophen as an alternative if NSAIDs are contraindicated. 1 If pain persists or muscle spasm is prominent after 2-4 days, add a short course (1-2 weeks maximum) of a skeletal muscle relaxant, preferably cyclobenzaprine or tizanidine. 1, 2, 3

First-Line Pharmacologic Approach

• NSAIDs are the most effective first-line medication for acute musculoskeletal pain, demonstrating superiority over placebo with moderate benefit (relative risk 1.24-1.29 for improvement). 1, 4

• Acetaminophen is a reasonable alternative with a more favorable safety profile than NSAIDs, though slightly less effective for pain relief. 2

• Limit NSAID use to the shortest duration necessary (typically 1-2 weeks) as most trial data only extends to 2 weeks, and long-term safety data is limited. 4

When to Add Muscle Relaxants

• Add a muscle relaxant if NSAIDs alone provide inadequate relief after 2-4 days, or if muscle spasm is a prominent clinical feature. 1, 2

• Cyclobenzaprine is FDA-approved as an adjunct to rest and physical therapy for relief of muscle spasm associated with acute, painful musculoskeletal conditions, and should only be used for short periods (2-3 weeks maximum). 3

• Tizanidine is the preferred alternative muscle relaxant based on demonstrated efficacy in multiple trials for acute musculoskeletal pain. 2, 5

• Skeletal muscle relaxants provide short-term pain relief (RR 1.25-1.72 for ≥30% improvement at 2-7 days) but are associated with increased sedation and CNS adverse effects (RR 2.04). 1

Important Clinical Considerations

• All skeletal muscle relaxants cause sedation as the primary adverse effect, requiring patient counseling about driving and operating machinery. 1, 2, 5

• Combining a muscle relaxant with an NSAID or acetaminophen provides greater pain relief than monotherapy, though it increases CNS adverse events (RR 2.44). 5

• Tizanidine requires monitoring for hepatotoxicity, which is generally reversible with discontinuation. 2, 5

• Avoid benzodiazepines (such as diazepam) as they show no superiority over other muscle relaxants and carry abuse potential. 1, 5

Non-Pharmacologic Adjuncts

• Advise patients to remain active and continue ordinary activities within pain limits, as bed rest is associated with worse outcomes. 1, 6

• Recommend ice application to painful areas and gentle stretching exercises. 6

• Consider manual physical therapy or spinal manipulation if no improvement occurs within 1-2 weeks of pharmacologic treatment. 1

What NOT to Do

• Do not prescribe opioids for non-specific musculoskeletal pain, as evidence does not support superiority over NSAIDs and risks outweigh benefits. 1

• Do not use systemic corticosteroids, as they have been shown ineffective for musculoskeletal back and neck pain. 1, 5

• Do not routinely order imaging unless red flags are present (severe neurologic deficits, suspected fracture, infection, or malignancy). 1

• Do not prescribe muscle relaxants beyond 2-3 weeks, as adequate evidence for prolonged use is not available and most acute musculoskeletal conditions resolve within this timeframe. 3, 2

Treatment Algorithm Summary

1. Start with NSAIDs (or acetaminophen if contraindicated) 1, 2
2. Reassess at 2-4 days 1
3. If inadequate response or prominent spasm, add cyclobenzaprine or tizanidine for maximum 2-3 weeks 2, 3
4. Counsel about sedation and monitor for adverse effects 1, 5
5. If no improvement after 1-2 weeks total, consider manual therapy or reassess diagnosis 1, 6