Treatment of Severe Muscle Spasm: Avoid Diazepam
Diazepam should NOT be used for severe muscle spasm; instead, initiate baclofen 10-30 mg/day as first-line therapy, combined with mandatory non-pharmacological interventions including stretching exercises, massage, and ice application. 1, 2
Why Diazepam Should Be Avoided
While the FDA has approved diazepam as "a useful adjunct for the relief of skeletal muscle spasm" 3, current clinical practice guidelines explicitly recommend against its use in most muscle spasm scenarios:
The American Heart Association recommends against diazepam or other benzodiazepines during stroke recovery due to possible deleterious effects on neurological recovery. 4, 2 This is a critical safety concern that extends beyond just stroke patients, as benzodiazepines can impair motor recovery and rehabilitation outcomes.
Benzodiazepines cause significant central nervous system side effects including drowsiness, dizziness, and sedation, with a number needed to harm (NNTH) of only 3 (95% CI 2 to 7). 5 This means for every 3 patients treated, one will experience adverse effects.
The American Geriatrics Society recommends avoiding muscle relaxants, particularly benzodiazepines, in elderly patients due to increased risk of falls, sedation, and anticholinergic effects. 2
First-Line Treatment: Baclofen
Baclofen is the evidence-based first-line pharmacological agent for severe muscle spasms:
Start baclofen at 10-30 mg/day for acute muscle spasms as recommended by the American College of Physicians. 1
For chronic spasticity conditions, initiate at lower doses (5-10 mg/day) and titrate slowly upward to minimize side effects, with typical maintenance dosing of 30-80 mg/day divided into 3-4 doses. 1, 2
Baclofen functions as a GABAB agonist and is most effective for spasticity-related muscle spasms rather than simple musculoskeletal pain. 1
Alternative First-Line Agent: Tizanidine
Tizanidine serves as an alternative first-line option:
The American Heart Association recommends tizanidine for spasticity resulting in pain, poor skin hygiene, or decreased function, particularly in chronic stroke patients. 4, 2
Tizanidine may be preferred when cardiovascular contraindications to baclofen exist. 1
Mandatory Non-Pharmacological Interventions
All pharmacological treatment MUST be accompanied by these interventions as recommended by the American College of Physicians: 1, 2
- Stretching exercises of affected muscles - this is not optional but essential
- Massage therapy to the affected area - required component of treatment
- Ice application for acute spasms - necessary non-pharmacological intervention
Treatment Algorithm for Severe Muscle Spasm
Step 1: Begin with non-pharmacological approaches 1, 2
- Positioning, range of motion exercises, stretching, splinting
- These should be initiated immediately
Step 2: Add oral baclofen if inadequate response 1, 2
- Start 10-30 mg/day for acute spasms
- Or 5-10 mg/day for chronic conditions, titrating to 30-80 mg/day divided into 3-4 doses
Step 3: Consider tizanidine as alternative 4, 2
- Particularly for stroke patients or when baclofen is contraindicated
Step 4: For refractory cases, consider advanced interventions 4
- Botulinum toxin or phenol/alcohol injections for selected patients
- Intrathecal baclofen for severe, refractory spasticity
Critical Safety Warnings
Never abruptly discontinue muscle relaxants after prolonged use - implement a slow tapering schedule to prevent withdrawal symptoms. 1, 2 This is particularly critical with baclofen, where abrupt cessation can cause life-threatening withdrawal syndrome.
Avoid carisoprodol due to significant drug abuse potential. 1, 2
Baclofen can cause dizziness, gastrointestinal symptoms, and may worsen obstructive sleep apnea. 1
Important Clinical Pitfall
Baclofen has minimal data supporting efficacy for non-spasticity-related pain conditions. 1 If the muscle spasm is associated with neuropathic pain without spasticity, gabapentinoids (pregabalin, gabapentin) are superior first-line choices rather than muscle relaxants.