What is the best treatment for muscle cramps?

Treatment of Muscle Cramps

For acute muscle cramps, immediately stop the triggering activity, stretch and massage the affected muscle, and apply ice; for recurrent or severe cramps, start baclofen 10 mg/day and titrate weekly by 10 mg increments up to 30 mg/day. 1, 2

Immediate Management of Acute Cramps

Non-pharmacological interventions are first-line treatment:

• Stop the activity that triggered the cramp immediately and rest the affected muscle 3, 1
• Stretch the cramping muscle actively while simultaneously massaging it to relieve the involuntary contraction 3, 1, 2
• Apply ice directly to the affected muscle during the acute episode 3, 1, 4

For heat-related cramps specifically, move to a cool environment, remove excess clothing, and drink electrolyte-carbohydrate mixtures such as juice, milk, or commercial sports drinks 3, 1. Do not resume exercise until all symptoms have completely resolved 3.

Pharmacological Treatment for Recurrent or Severe Cramps

Baclofen is the first-line pharmacological agent with high-quality evidence:

• Start at 10 mg once daily (or 5 mg three times daily in older adults to minimize side effects) 1, 2, 4
• Increase by 10 mg weekly up to a maximum of 30 mg/day 1, 2, 4
• Monitor for dizziness, somnolence, gastrointestinal symptoms, muscle weakness, and cognitive impairment, particularly in older adults 2
• Never discontinue abruptly after prolonged use—taper slowly to prevent withdrawal symptoms including CNS irritability and seizures 2

In patients with liver disease, baclofen 10-30 mg/day is particularly effective, but monitor closely for hepatic encephalopathy 1, 2. Human albumin 20-40 g/week may provide additional benefit in cirrhotic patients 1.

Electrolyte Correction

Correct documented deficiencies, not empiric supplementation:

• Check serum potassium and magnesium levels before supplementing 1, 2
• For documented hypomagnesemia, use magnesium oxide 12-24 mmol daily (480-960 mg) given at night 2, 4
• Always correct water and sodium depletion first, as secondary hyperaldosteronism worsens magnesium losses 2, 4
• Avoid magnesium supplementation in renal insufficiency—magnesium is renally excreted and can accumulate to toxic levels 2, 4

Medications to Avoid

Several commonly considered agents have unfavorable risk-benefit profiles:

• Quinidine is not recommended despite effectiveness at 400 mg/day for 4 weeks, due to significant cardiac toxicity and FDA warnings 1, 2
• Cyclobenzaprine should not be prescribed with the mistaken belief that it directly relieves muscle spasm—it does not 1, 2
• Benzodiazepines have limited efficacy for persistent cramps and carry high risk profiles, especially in older adults 1

Special Population Considerations

For older adults (≥65 years):

• Start baclofen at lower doses (5 mg three times daily maximum initially) 2
• Monitor carefully for muscle weakness, urinary dysfunction, cognitive effects, and sedation 2

For athletes and exercise-associated cramps:

• Maintain hydration with carbohydrate-electrolyte beverages (0.5-0.7 g/L sodium, increasing to 1.5 g/L if cramping persists) during prolonged exercise in heat 2
• Include 30-60 g/hour of carbohydrates for exercise lasting >1 hour 2
• Review medications affecting hydration or thermoregulation (dopamine reuptake inhibitors, diuretics) before training in hot environments 2

For patients with cirrhosis:

• Consider reducing or discontinuing diuretics if cramps are incapacitating 2
• Monitor serum creatinine, sodium, and potassium during treatment, especially during the first month 1
• Orphenadrine or methocarbamol can be considered as alternatives 1

When to Investigate Further

Pursue diagnostic workup if cramps are:

• Severe in intensity and frequency 5
• Associated with abnormal neurological examination findings 5
• Accompanied by muscle weakness, fasciculations, or atrophy 5, 6

Consider electromyography and comprehensive metabolic panel to rule out motor unit diseases (neuropathy, radiculopathy, neuromyotonia, or cramp-fasciculation syndrome that can precede ALS), metabolic disorders, or medication side effects 5, 6, 7.