What are the treatment options for myalgia (muscle pain)?

From the Guidelines

For muscle pain treatment, I recommend starting with non-pharmacological approaches, such as physical therapy, heat/cold, and orthotics, before considering pharmacological treatments. According to the American Heart Association, initial treatment should focus on nonpharmacological approaches, and pharmacological treatments should only be considered if symptoms are not controlled by these methods 1.

Key Considerations

• When choosing any medication, both safety and efficacy should be considered, and the least risky medication should be tried first, with escalation only if the first medication is ineffective 1.
• Nonsteroidal anti-inflammatory drugs (NSAIDs) have anti-inflammatory and antipyretic properties, but their use is limited to patients not at risk for coronary artery disease 1.
• Antidepressants, such as tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), and serotonin-norepinephrine reuptake inhibitors (SNRIs), can exert analgesic effects, but their use is limited by cardiovascular side effects 1.

Treatment Approach

• Start with NSAIDs like ibuprofen (400-600mg every 6-8 hours, not exceeding 3200mg daily) or naproxen (220-440mg twice daily, maximum 1000mg daily) for 3-5 days to reduce inflammation and pain.
• Apply ice for acute injuries (20 minutes on, 20 minutes off) during the first 48 hours, then switch to heat therapy using warm compresses or heating pads for 15-20 minutes several times daily.
• Gentle stretching and progressive movement help maintain flexibility and promote healing.
• For persistent pain, topical treatments like menthol-containing creams (applied 3-4 times daily) or lidocaine patches (applied for up to 12 hours daily) can provide localized relief.
• Ensure adequate hydration and consider magnesium supplements (300-400mg daily) if muscle cramps are frequent.

Monitoring and Follow-up

• If pain persists beyond 7-10 days, worsens significantly, or is accompanied by severe swelling, redness, or fever, consult a healthcare provider as these may indicate a more serious condition requiring medical intervention.
• Clinicians should assess cardiovascular and gastrointestinal risk factors before prescribing NSAIDs and recommend the lowest effective doses for the shortest periods necessary 1.

From the FDA Drug Label

Cyclobenzaprine hydrochloride tablets are indicated as an adjunct to rest and physical therapy for relief of muscle spasm associated with acute, painful musculoskeletal conditions Improvement is manifested by relief of muscle spasm and its associated signs and symptoms, namely, pain, tenderness, limitation of motion, and restriction in activities of daily living NSAID medicines are used to treat pain and redness, swelling, and heat (inflammation) from medical conditions such as: different types of arthritis menstrual cramps and other types of short-term pain

Muscle Pain Treatment:

• Cyclobenzaprine is indicated for relief of muscle spasm associated with acute, painful musculoskeletal conditions, which includes muscle pain.
• Naproxen is used to treat pain and inflammation from medical conditions, which can include muscle pain. The most suitable treatment option would be cyclobenzaprine for muscle spasm associated with acute, painful musculoskeletal conditions, or naproxen for pain and inflammation. 2 3

From the Research

Treatment Options for Muscle Pain

• Muscle relaxants can be used to treat acute and chronic pain, with various types available and potential adverse effects to consider 4
• For acute mild to moderate pain, first-line treatment options include acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs), with topical NSAIDs recommended for non-low back, musculoskeletal injuries 5
• Adjunctive medications, such as muscle relaxants, may be added for specific conditions if first-line agents are inadequate, and opioids may be used for severe or refractory acute pain with caution 5

Medications for Acute Low Back Pain

• A randomized clinical trial compared functional outcomes and pain at 1 week and 3 months after an ED visit for acute low back pain among patients randomized to naproxen + placebo, naproxen + cyclobenzaprine, or naproxen + oxycodone/acetaminophen, finding no improvement with added medications 6
• The study suggests that adding cyclobenzaprine or oxycodone/acetaminophen to naproxen alone may not improve functional outcomes or pain at 1-week follow-up for patients with acute, nontraumatic, nonradicular low back pain 6

Pharmacological Profile of Non-Opioid Analgesics

• Non-opioid analgesics, such as aspirin, paracetamol (acetaminophen), ibuprofen, and phenazones, are believed to act via inhibition of cyclo-oxygenase, with differing inhibitory potency and pharmacokinetic parameters 7
• The suitability of non-opioid analgesics in everyday practice is determined by their pharmacokinetic parameters, which have therapeutic implications 7