Medication Summary
The goal of medication for patients with cervical myofascial syndrome is to reduce pain. Avoid the use of opioid analgesics. If the clinical picture is one of more chronic pain accompanied by sleep dysfunction, consider the use of a tricyclic antidepressant (TCA). Anticonvulsants used as neuropathic analgesics may be helpful, because myofascial pain may at its core be a spinal-mediated disorder affected by neuropathic dysfunction. Muscle relaxants, although commonly administered to treat muscle pain, must be used cautiously because of their sedative effects and, in some cases, addictive potential. [12]
Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)
Class Summary
NSAIDs are the drugs of choice for the initial treatment of myofascial pain.
Ibuprofen (Motrin, Advil, Neoprofen, Ultraprin)
Ibuprofen inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis. It is used to provide relief of cervical myofascial pain.
Indomethacin (Indocin)
Indomethacin is thought to be the most effective NSAID for the treatment of ankylosing spondylitis, although no scientific evidence supports this claim. It is used for relief of mild to moderate pain; it inhibits inflammatory reactions and pain by decreasing the activity of COX, which results in a decrease of prostaglandin synthesis.
Naproxen (Naprosyn, Naprelan, Aleve, Anaprox)
Naproxen is used for relief of mild to moderate pain; it inhibits inflammatory reactions and pain by decreasing the activity of COX, which results in a decrease of prostaglandin synthesis.
Diclofenac (Voltaren, Cataflam XR, Zipsor, Cambia)
Diclofenac inhibits prostaglandin synthesis by decreasing COX activity, which, in turn, decreases formation of prostaglandin precursors.
Ketoprofen
Ketoprofen is used for relief of mild to moderate pain and inflammation. Small dosages are indicated initially in small patients, elderly patients, and patients with renal or liver disease. Doses higher than 75 mg do not increase the therapeutic effects. Administer high doses with caution, and closely observe the patient's response.
Tricyclic Antidepressants
Class Summary
Tricyclic antidepressants are commonly used for chronic pain. They help to treat insomnia and reduce painful dysesthesia. These agents treat nociceptive and neuropathic pain syndromes.
Amitriptyline
Amitriptyline inhibits the reuptake of serotonin and/or norepinephrine at the presynaptic neuronal membrane, which increases their concentration in the central nervous system (CNS). Amitriptyline may increase or prolong neuronal activity, since the reuptake of these biogenic amines is important physiologically in terminating transmitting activity.
Skeletal Muscle Relaxants
Class Summary
Muscle relaxants are commonly used to treat muscle pain, but they must be used cautiously because of sedation and because of the addictive potential of some of the medications in this category of drugs (benzodiazepines).
Cyclobenzaprine (Flexeril, Fexmid, Amrix)
Cyclobenzaprine acts centrally and reduces motor activity of tonic somatic origins, influencing alpha and gamma motor neurons. It is structurally related to the tricyclic antidepressants.
Skeletal muscle relaxants have modest, short-term benefit as adjunctive therapy for nociceptive pain associated with muscle strains and, used intermittently, for diffuse and certain regional chronic pain syndromes. Long-term improvement over placebo has not been established.
Cyclobenzaprine often produces a "hangover" effect, which can be minimized by taking the nighttime dose 2-3 hours before going to sleep.
Baclofen (Lioresal, Gablofen)
Baclofen is metabolized in the liver and excreted primarily in urine. This agent is not a controlled substance under the Drug Enforcement Administration (DEA).
Carisoprodol (Soma)
Carisoprodol is a short-acting medication that may have depressant effects at the spinal cord level.
Skeletal muscle relaxants have modest short-term benefit as adjunctive therapy for nociceptive pain associated with muscle strains and, used intermittently, for diffuse and certain regional chronic pain syndromes. Long-term improvement over placebo has not been established.
Tizanidine (Zanaflex)
Tizanidine is a centrally acting muscle relaxant that is metabolized in the liver and excreted in the urine and feces. It is used in patients with predominantly upper motor neuron involvement. It is not a DEA-controlled substance.
Opioid Analgesics
Class Summary
Tramadol is a weak opioid and an inhibitor of serotonin and norepinephrine reuptake in the dorsal horn. Studies have shown efficacy when it has been used to treat fibromyalgia, although no formal studies have been performed for myofascial pain. Tramadol is known to help with chronic low back pain and osteoarthritic pain, both of which are commonly associated with myofascial pain.
Tramadol (Ultram, Ryzolt)
Tramadol is an analgesic that probably acts over monoaminergic and opioid mechanisms. Its monoaminergic effect is shared with tricyclic antidepressants. Tolerance and dependence appear to be uncommon.
Anticonvulsants, Other
Class Summary
Anticonvulsants used as neuropathic analgesics may be helpful, because myofascial pain may at its core be a spinal-mediated disorder affected by neuropathic dysfunction. Gabapentin has been shown to be effective in treating myofascial and neuropathic pain.
Gabapentin (Neurontin)
Gabapentin is a membrane stabilizer. It is a structural analogue of the inhibitory neurotransmitter gamma-aminobutyric acid (GABA), but, paradoxically, it is thought not to exert an effect on GABA receptors. Gabapentin appears to exert action via the alpha(2)delta1 and alpha(2)delta2 auxiliary subunits of voltage-gaited calcium channels. It is used to manage pain and provide sedation in neuropathic pain.
Titration to effect occurs over several days (300 mg on day 1, 300 mg twice on day 2, and 300 mg 3 times on day 3).
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Schematic of a trigger point complex of a muscle in longitudinal section. A: The central trigger point (CTrP) in the endplate zone contains numerous electrically active loci and numerous contraction knots. A taut band of muscle fibers extends from the trigger point to the attachment at each end of the involved fibers. The sustained tension that the taut band exerts on the attachment tissues can induce a localized enthesopathy that is identified as an attachment trigger point (ATrP). B: Enlarged view of part of the CTrP shows the distribution of 5 contraction knots. The vertical lines in each muscle fiber identify the relative spacing of its striations. The space between 2 striations corresponds to the length of 1 sarcomere. The sarcomeres within one of these enlarged segments (ie, contraction knot) of a muscle fiber are markedly shorter and wider than the sarcomeres in the neighboring normal muscle fibers, which are free of contraction knots.
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Cross-sectional drawing shows flat palpation of a taut band and its trigger point. Left: A. The skin is pushed to one side to begin palpation. B. The fingertip slides across muscle fibers to feel the cord-line texture of the taut band rolling beneath it. C. The skin is pushed to the other side at completion of the movement. This same movement performed vigorously is called snapping palpation. Right: A. Muscle fibers are surrounded by the thumb and fingers in a pincer grip. B. The hardness of the taut band is felt clearly as it is rolled between the digits. C. The palpable edge of the taut band is sharply defined as it escapes from between the fingertips, often with a local twitch response.
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Longitudinal schematic drawing of taut bands, myofascial trigger points, and a local twitch response. A: Palpation of a taut band (straight lines) among normally slack, relaxed muscle fibers (wavy lines). B: Rolling the band quickly under the fingertip (snapping palpation) at the trigger point often produces a local twitch response, which usually is seen most clearly as skin movement between the trigger point and the attachment of the muscle fibers.
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Cross-sectional schematic drawing shows flat palpation to localize and hold the trigger point for injection. A and B show the use of alternate pressure between 2 fingers to confirm the location of the palpable module of the trigger point. C shows the trigger point being positioned halfway between the fingertips to keep it from sliding to one side during the injection.
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Sequence of steps to use when stretching and spraying any muscle for myofascial trigger points.
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Schematic drawing showing how the jet stream of vapocoolant is applied.
