What is the best approach to manage mastalgia (breast pain) in a patient?

Management of Mastalgia

The best approach to managing mastalgia is to provide reassurance after appropriate clinical evaluation, followed by non-pharmacological measures (supportive bra, NSAIDs), which resolves symptoms in 86% of mild cases and 52% of severe cases without need for pharmacological intervention. 1

Initial Evaluation and Risk Stratification

Classify the pain type first to guide your management approach:

• Cyclical mastalgia (70% of cases): Bilateral or diffuse, waxes and wanes with menstrual cycle, hormonal in origin 1
• Noncyclical mastalgia (25% of cases): Unilateral, focal, often subareolar or lower inner breast, inflammatory rather than hormonal 1
• Extramammary pain (10-15% of cases): Musculoskeletal (costochondritis, muscle strains), nerve entrapment, or referred pain from cardiac/pulmonary/GI sources 1

Determine if imaging is needed:

• For diffuse/non-focal pain with normal clinical exam: No imaging needed—proceed directly to reassurance and symptomatic management 2
• For focal pain: Obtain diagnostic mammogram with ultrasound in women ≥30 years; ultrasound alone in women <30 years 1
• Important caveat: While cancer risk is extremely low (0.4-0.8%), invasive lobular carcinoma and anaplastic carcinoma are disproportionately associated with mastalgia, so do not dismiss focal pain without proper evaluation 3, 4

First-Line Management: Reassurance and Non-Pharmacological Measures

Start with reassurance that breast pain alone rarely indicates cancer—this single intervention resolves symptoms in the majority of patients 1, 4

Implement these non-pharmacological measures:

• Well-fitted supportive bra, especially during exercise—essential for women with large breasts 1
• Over-the-counter NSAIDs (ibuprofen) for symptomatic relief 1
• Ice packs or heating pads for comfort 1
• Regular physical exercise to alleviate symptoms 1

Address modifiable factors:

• For smokers with periductal inflammation and burning nipple pain: Advise smoking cessation 1
• Caffeine reduction: Despite widespread belief, there is no convincing scientific evidence that eliminating caffeine significantly affects breast pain 1, 4
• Review medications: Oral contraceptives, hormone therapy, psychotropic drugs, and cardiovascular agents can cause mastalgia 5

Special Considerations by Pain Type

For noncyclical mastalgia:

• Hormonal treatments are generally ineffective 1
• Pain resolves spontaneously in up to 50% of cases 4
• If simple cysts correlate with focal pain: Consider drainage for symptom relief 1

For cyclical mastalgia:

• Responds better to hormonal manipulation than noncyclical pain 3
• May resolve spontaneously in 14-20% within 3 months 3
• Recurs in at least 60% within 2 years 3

For pregnancy/breastfeeding-related pain:

• Reassurance is key—pain is usually self-limiting 1

Adjunctive Therapies

For premenstrual mastalgia specifically:

• Acupressure: Bilateral stimulation of Large Intestine-4 (LI4) point during symptomatic periods can be offered as adjunctive therapy 1
• Spleen-6 (SP6) stimulation: Effective for primary dysmenorrhea and may help with premenstrual breast pain 1
• Patients can perform self-stimulation at home 1

For musculoskeletal components:

• Physical therapy with stretching exercises has been shown effective for managing musculoskeletal symptoms contributing to breast pain 1

Critical Pitfalls to Avoid

Do not dismiss breast pain without proper evaluation—advanced cancers can present with pain as the only symptom, especially if deep in large breasts or with chest-wall invasion 3, 4

Do not order unnecessary imaging for diffuse, non-focal breast pain when clinical exam is normal—this increases additional clinical and imaging utilization without increasing cancer detection 3, 2

Do not fail to consider extramammary causes when breast exam and imaging are normal—these account for 10-15% of cases and include costochondritis, nerve entrapment, coronary ischemia, esophageal disease, and even infected teeth 3, 2

Do not use hormonal agents as first-line therapy—they have significant side effects and should be reserved for severe, persistent cases unresponsive to conservative measures 4

Do not continue ineffective treatments beyond 3 months without reassessing the diagnosis 4