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Which muscle relaxants are best for neck and back pain?

by Dr. Sharon Orrange on April 20, 2017 at 4:08 pm

Whether from a new injury or an aggravated old injury, stiffness and soreness in the neck and back at night may lead to disrupted sleep and more pain in the morning. Muscle relaxants have been shown to help relieve this pain and get you through these tough days—used at night, these medications may improve acute neck and back pain.

Your first line treatment will still be acetaminophen (Tylenol) and NSAIDs (ibuprofen, Advil, naproxen, Aleve, etc) which do work better for neck and back pain than muscle relaxants. But there may be benefit to taking both, especially at night, where a muscle relaxant added to acetaminophen or an NSAID works better than either alone.

Let’s compare them. How well do they work and what are their side effects ? Oh, and are they affordable?

  • Methocarbamol (Robaxin). An inexpensive and less sedating option, methocarbamol has been well studied for use in back pain. In recent studies where it was used for up to 8 days, 44% of folks had complete pain relief with methocarbamol (compared to 18% who did nothing) without any serious side effects. Taken as needed, 1500 mg every 6 to 8 hours is a cheap and well-tolerated option for sufferers of acute neck and back pain. Think of trying this first, as it is less sedating than cyclobenzaprine and carisoprodol.
  • Cyclobenzaprine (Flexeril). At the standard dose of 10 mg to 30 mg a day, cyclobenzaprine will make you sleepy. If used during the day you’ll want to break your 10 mg tab in half and take 5 mg to lessen the drowsiness. Interestingly, 5 mg three times a day has been shown in studies to work as well as 10 mg taken three times a day. Cyclobenzaprine is a reasonable first choice because it’s a cheap generic, but the sedation side effect limits its use during the day. Cyclobenzaprine has anticholinergic properties, similar to Robaxin (methocarbamol) and Soma (carisoprodol), so it may cause more sedation and dry mouth, especially in older folks. If this is a concern, consider a better non-sedating option.
  • Carisoprodol (Soma) has an abuse potential so should not be used if there is a history of substance abuse. For this reason, it is a schedule IV drug similar to the benzodiazepines (Ativan, Valium, Xanax, etc). General opinion is that carisoprodol should be phased out as a muscle relaxant in favor of much better options. If prescribed, carisoprodol should only be used for short periods (2-3 weeks) due to lack of evidence for effectiveness with longer use. It may cause drowsiness and dizziness, and should not be used in folks over 65.
  • Metaxalone (Skelaxin). Taken as 800 mg tablets, three to four times a day, metaxalone has the fewest reported side effects and less sedation in studies. Simply put, it is the best tolerated of the muscle relaxants. Metaxolone is a generic alternative for Skelaxin, but it is still pricey and insurance companies don’t like to cover it because there are cheaper alternatives.Having said that, it works as well as cyclobenzaprine and carisoprodol with fewer side effects and less sedation—so paying cash may be worth it.
  • Tizanidine (Zanaflex). Tizanidine is used more for spasticity in patients with multiple sclerosis or cerebral palsy. In head to head studies with Baclofen for those conditions, it tends to be better tolerated (it has fewer side effects)—but they both work just as well. This is not a first line choice for acute neck or back muscle pain though.
  • Baclofen. Similar to tizanidine, Baclofen is primarily used for spasticity in spinal cord injury patients or those with multiple sclerosis. Drowsiness occurs in up to 20% of folks taking it, and there are better options for neck and back muscle pain. Also not a first choice.
  • Oxazepam. Benzodiazepines like oxazepam and diazepam (Valium), are sometimes prescribed as muscle relaxants. However, these really aren’t recommended because they don’t work well, are sedating, and can be habit forming. Avoid benzodiazepines for neck and back muscle pain because there are much better options.
  • Chlorzoxazone (Lorzone). This one is not well-studied for acute low back and neck pain in adults, and when investigated for pain after spine surgery, it wasn’t found to be effective. Chlorzoxazone has also been reported as a rare cause of acute liver toxicity. Don’t choose this until you’ve exhausted all other options.
  • Orphenadrine (Norflex). For neck and back pain in adults, the first four medications on this list (cyclobenzaprine, carisoprodol, methocarbamol, and metaxalone) work better than Norflex so save this as another last resort in the event the others don’t work. It just hasn’t been well studied for this purpose.

Dr O.

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