What are the treatment options for muscle pain?

Treatment of Muscle Pain

For acute non-low back musculoskeletal pain, start with topical NSAIDs with or without menthol gel as first-line therapy, followed by oral NSAIDs or acetaminophen if needed, while avoiding opioids and using muscle relaxants only when necessary with preference for tizanidine over other agents. 1

First-Line Treatment: Topical NSAIDs

• Topical NSAIDs with or without menthol gel should be the initial treatment to reduce pain, improve physical function, and enhance treatment satisfaction 1
• This represents a strong recommendation based on moderate-certainty evidence from the American College of Physicians and American Academy of Family Physicians 1
• Topical formulations minimize systemic absorption and associated cardiovascular risks compared to oral NSAIDs 1

Second-Line Treatment: Oral Analgesics

Oral NSAIDs and Acetaminophen

• Oral NSAIDs are recommended to reduce pain and improve physical function when topical therapy is insufficient 1
• Acetaminophen is an appropriate alternative specifically for pain reduction 1, 2
• Acetaminophen temporarily relieves minor aches and pains due to muscular aches, with dosing of 2 caplets every 8 hours (maximum 6 caplets in 24 hours, not exceeding 10 days without physician direction) 2
• In emergency department studies of acute musculoskeletal injuries, ibuprofen 800 mg and acetaminophen 1 g showed similar pain reduction (approximately 20 mm on visual analog scale), with no additional benefit from combining them 3

Stepped-Care Approach for Patients with Cardiovascular Disease

For patients with known cardiovascular disease or risk factors, follow this hierarchy 1:

1. Start with acetaminophen, aspirin, tramadol, or short-term narcotic analgesics 1
2. Progress to nonacetylated salicylates if needed 1
3. Consider non-COX-2 selective NSAIDs (such as naproxen) if initial therapy is insufficient 1
4. NSAIDs with COX-2 selectivity should only be used when intolerable discomfort persists despite stepped-care attempts, using the lowest effective dose for the shortest time 1
5. Ibuprofen should not be used because it blocks the antiplatelet effects of aspirin 1

Critical Cardiovascular Warnings for NSAIDs

• NSAIDs increase risk of heart attack, stroke, and death, particularly in patients with established cardiovascular disease 1, 4
• Do not use NSAIDs right before or after coronary artery bypass graft surgery 4
• NSAIDs increase risk of bleeding, ulcers, and gastrointestinal perforation, especially with longer use, higher doses, advanced age, alcohol use, smoking, or concurrent use of corticosteroids, anticoagulants, SSRIs, or SNRIs 4
• Avoid NSAIDs after 30 weeks of pregnancy due to potential harm to the unborn baby 4

Muscle Relaxants: Use Sparingly and Selectively

When to Consider Muscle Relaxants

• Muscle relaxants should be reserved for situations where analgesics alone are insufficient 5, 6
• Adding a muscle relaxant to an NSAID or acetaminophen provides greater short-term pain relief than analgesic monotherapy, though this increases CNS adverse events 5
• The term "muscle relaxant" is misleading—these drugs do not relieve muscle spasm through direct muscle relaxation; their effects are nonspecific 5

Preferred Agent: Tizanidine

• Tizanidine is recommended as the safest muscle relaxant alternative due to its favorable efficacy and safety profile 5
• Start at 2-4 mg with upward titration as needed 5
• Monitor for hepatotoxicity, which is generally reversible 5

Agents to Avoid

• Avoid benzodiazepines (diazepam, lorazepam) due to abuse potential, high fall risk in older adults, and lack of proven benefit 5, 7
• In rheumatoid arthritis patients, benzodiazepines (diazepam, triazolam) showed no pain improvement over 24 hours to one week, but caused significant drowsiness and dizziness (number needed to harm = 3) 7
• Carisoprodol is a controlled substance with substantial abuse potential, barbiturate-like action, and severe withdrawal symptoms (insomnia, vomiting, tremors, anxiety, hallucinations) 6
• Carisoprodol should be avoided despite showing superiority over diazepam in some trials, as non-benzodiazepine alternatives (cyclobenzaprine, methocarbamol, metaxalone) have similar efficacy without controlled substance classification 6

Alternative Muscle Relaxant Options

• Cyclobenzaprine is structurally similar to tricyclic antidepressants with expected anticholinergic effects 5
• For elderly patients requiring muscle relaxant therapy, baclofen is preferred, starting at 5 mg three times daily with gradual titration 6
• Muscle relaxants are effective for short-term (2-3 weeks maximum) symptomatic relief in acute musculoskeletal conditions 6

Adjuvant Therapies

Non-Pharmacological Interventions

• Acupuncture is recommended to reduce pain and improve physical function in acute musculoskeletal injuries 1
• Transcutaneous electrical nerve stimulation (TENS) can reduce pain 1
• Physical activity, physical therapy, and rehabilitation should be offered based on clinical indication 1

Adjuvant Analgesics for Specific Pain Types

For neuropathic or chronic widespread muscle pain (such as fibromyalgia):

• Duloxetine (SNRI) and tricyclic antidepressants are effective for neuropathic pain and fibromyalgia 1
• Gabapentin and pregabalin (gabapentinoids) are recommended for neuropathic pain and fibromyalgia 1
• These adjuvant analgesics can be used alone or coadministered with opioids to enhance analgesia 1

For aromatase inhibitor-associated muscle pain in breast cancer survivors:

• Acupuncture and intensive exercise regimens have demonstrated statistically significant improvement 1
• NSAIDs and acetaminophen are often not responsive for this specific pain type 1

What NOT to Do

Avoid Opioids

• The American College of Physicians and American Academy of Family Physicians recommend against treating acute musculoskeletal pain with opioids, including tramadol 1
• This is a conditional recommendation based on low-certainty evidence, but reflects the significant risks of opioid use disorder and adverse events 1
• If opioids are deemed necessary, use the lowest dose possible, reevaluate regularly, and consider pain treatment agreements 1

Duration Limits

• Do not use acetaminophen for more than 10 days without physician direction 2
• Do not use over-the-counter NSAIDs for more than 10 days without consulting a healthcare provider 4
• Muscle relaxants should be limited to short-term use (2-3 weeks maximum) 6

Special Populations

Older Adults

• Muscle relaxants carry increased fall risk, particularly in older persons 5
• Benzodiazepines have a high risk profile in older adults that usually obviates any potential benefit 5
• If muscle relaxant therapy is required in elderly patients, baclofen is preferred 6

Patients with Cardiovascular Disease

• Follow the stepped-care approach outlined above, starting with acetaminophen or non-acetylated salicylates 1
• Prescribe the lowest dose required to control symptoms 1
• Consider adding aspirin 81 mg and a proton-pump inhibitor for patients at increased risk of thrombotic events, though this may not provide sufficient protection 1

Cancer Survivors

• Assess musculoskeletal symptoms at each clinical encounter 1
• Offer acetaminophen, NSAIDs, physical activity, and/or acupuncture for pain 1
• For bone pain, consider osteoclast inhibitors (bisphosphonates or denosumab) 1