In a healthy adult with temporomandibular joint pain and persistent muscle spasm despite adequate nonsteroidal anti‑inflammatory drug therapy and jaw‑exercise/physical‑therapy, should a short course of a centrally acting skeletal muscle relaxant be added, and if so, which agent and dosing regimen?

Should a Muscle Relaxant Be Added for TMJ Pain with Persistent Muscle Spasm?

No, muscle relaxants should not be routinely added as the next step in this clinical scenario. The highest-quality recent guidelines conditionally recommend against acetaminophen with or without muscle relaxants for TMJ disorders due to uncertain efficacy 1. Instead, you should escalate to evidence-based non-pharmacologic interventions that have demonstrated superior effectiveness.

Why Muscle Relaxants Are Not Recommended

• The American College of Physicians (2023) conditionally recommends against acetaminophen with or without muscle relaxants for chronic TMJ pain due to uncertain benefits and lack of evidence demonstrating meaningful clinical improvement 1, 2.

• Although cyclobenzaprine is FDA-approved as an adjunct to rest and physical therapy for acute painful musculoskeletal conditions with muscle spasm 3, this indication applies to short-term use (2-3 weeks) in acute conditions 3, not the chronic TMJ dysfunction described in your scenario.

• The 2024 systematic review and network meta-analysis found that muscle relaxants may have some role in TMD-M (muscle-origin TMD) 4, but this evidence is substantially weaker than the guideline-level recommendations against their routine use 1, 2.

What You Should Do Instead

First-Line Escalation: Add Evidence-Based Non-Pharmacologic Therapies

Before considering any additional pharmacologic agents, you must add the following interventions, which provide pain relief 1.5-2 times the minimally important difference:

• Manual trigger point therapy – provides the largest pain reductions, approaching twice the minimally important difference 1, 5

• Therapist-assisted jaw mobilization – improves joint mobility and reduces pain through manual techniques 1, 5

• Supervised jaw exercises with stretching – reduces pain by approximately 1.5 times the minimally important difference 1, 5

• Cognitive behavioral therapy (CBT) – addresses pain perception and psychological factors; CBT augmented with relaxation/biofeedback provides the greatest overall pain relief 1, 2

• Supervised postural exercises – corrects head and neck alignment to reduce TMJ strain 1, 2

Critical Implementation Point

These interventions are strongly recommended with moderate-to-high certainty evidence and carry no serious harms 2. The majority (85-90%) of TMJ pain is muscular (extra-articular) in origin 2, making these muscle-directed therapies the mechanistically appropriate choice rather than systemic muscle relaxants.

If You Must Consider Pharmacologic Escalation

Second-Line Pharmacologic Option (Only After Non-Pharmacologic Failure)

If NSAIDs remain partially effective but insufficient, combine them with CBT rather than adding a muscle relaxant 1, 5. This combination is conditionally recommended as a second-line approach 1, 5.

What NOT to Do

• Never combine NSAIDs with opioids – this is strongly recommended against due to increased harm (GI bleeding, addiction, overdose) without additional analgesic benefit 1, 2, 5

• Avoid benzodiazepines and beta-blockers – conditionally recommended against due to potential harms 2

• Do not rely on occlusal splints unless documented bruxism is present – conditionally recommended against for general TMJ dysfunction 1, 5

Clinical Algorithm for Your Patient

1. Verify adequate NSAID therapy – ensure appropriate dosing and duration 1

2. Immediately refer to physical therapy with TMJ expertise for manual trigger point therapy, jaw mobilization, and supervised exercises 1, 5

3. Initiate or refer for CBT – especially if psychological stressors or catastrophizing are present 1, 2

4. Continue patient education – activity modification, soft diet, heat/cold application 1, 5

5. Reassess after 4-6 weeks of this intensified conservative management 2

6. If still refractory after 3-6 months of comprehensive conservative treatment, consider referral to a multidisciplinary TMJ team (oral/maxillofacial surgery, orofacial pain specialist, physical therapist) 5

Common Pitfalls to Avoid

• Assuming muscle spasm requires a muscle relaxant – the evidence shows that manual therapies and exercises are far more effective for TMJ-related muscle dysfunction than systemic muscle relaxants 1, 2, 5

• Proceeding to pharmacologic escalation before exhausting non-pharmacologic options – this violates guideline recommendations and deprives patients of the most effective treatments 1, 5

• Prescribing NSAIDs as monotherapy – NSAIDs must be combined with non-pharmacologic interventions; using them alone is conditionally recommended against 1

If Muscle Relaxant Use Is Unavoidable

Only if the patient has failed all evidence-based non-pharmacologic interventions AND has documented acute exacerbation of muscle spasm, cyclobenzaprine may be considered:

• Dosing: 5 mg three times daily (lower dose shown effective in clinical trials) 3 or 10 mg at bedtime to minimize daytime drowsiness 3

• Duration: Maximum 2-3 weeks only 3

• Monitoring: Warn about drowsiness, especially when combined with NSAIDs (increased side effects documented) 3

• Contraindications: Do not use with MAO inhibitors, in acute recovery phase of MI, or in patients with arrhythmias, heart block, or hyperthyroidism 3

However, this approach lacks guideline support and should be considered a deviation from evidence-based care 1, 2.