Best treatments for headache, neck, and lower-back pain

If you've ever had a back or neck muscle spasm, you know it can be exceptionally painful, and even debilitating. Muscle relaxants are widely used to treat these conditions, although there is limited evidence they actually help relieve symptoms. Many experts think the drugs' side effect of sedation is what actually helps people. But some of the drugs pose a risk of serious problems, including liver toxicity and addiction.

If you suffer from a headache, back ache, neck pain, or other conditions that cause muscle spasms, first try other therapies that don't involve medications, such as using a heating pad, exercise, biofeedback, or progressive relaxation, massage, or yoga.

If those don't help, a good next step is to try over-the-counter pain relievers, such as acetaminophen (Tylenol and generics), ibuprofen (Advil and generics), or naproxen (Aleve and generics). Adding a muscle relaxant to the mix has not been shown in studies to be any better at providing relief from this kind of pain than just taking one of the OTC pain relievers.

If you can't tolerate the over-the-counter pain medications because you have other conditions, such as kidney or liver problems, bleeding ulcers, or heart issues, then you together with your doctor may want to consider taking a muscle relaxant as a temporary measure. People with liver or kidney disease, heart issues, or glaucoma should not use them, however.

We haven't chosen any muscle relaxant as a Best Buy because there are few good-quality studies that show they are effective. Additionally, they also pose serious safety concerns, particularly for elderly people.

If you decide to try a muscle relaxant, they should not be taken for longer than three weeks. In addition to sedation, the most common side effects of muscle relaxants include dizziness, dry mouth, fatigue, and weakness.

Safety Note: We recommend avoiding carisoprodol (Soma) because it is associated with a high risk of abuse and addiction potential not seen with other muscle relaxants.

Muscle relaxants is a broad category that includes a set of drugs that work in different ways. They are grouped together because they are approved by the U.S. Food and Drug Administration (FDA) to treat similar conditions and disorders. The result is that each medication may affect you—in terms of benefits and side effects—quite differently.

Many of the available studies on these medications are old and don't meet today's standards for high-quality research. So despite the widespread use of muscle relaxants, the evidence for several of these drugs is sparse or of low-quality. This makes it difficult to determine if any of the muscle relaxants are more effective or pose more safety concerns than others.

There are six muscle relaxants approved to treat back or neck aches, headaches, and other conditions that are due to painful muscle spasms. As you can see, all are available in generic forms. A few are available in combination with aspirin, codeine, and/or caffeine.

Table 1. Muscle relaxants

If you have a headache, backache, neck pain, or other conditions that are from having a muscle spasm, first try other therapies that don't involve medications, such as a heating pad, exercise, biofeedback, or progressive relaxation, massage, or yoga.

If those don't help, try over-the-counter pain relievers, such as acetaminophen (Tylenol and generics), ibuprofen (Advil and generics), or naproxen (Aleve and generics). Studies that compared those OTC pain relievers with muscle relaxants mostly found little difference in how well they improved pain or function—but the muscle relaxants were associated with much more sedation.

Taking an OTC pain reliever along with a muscle relaxant has not been shown to work any better than an OTC pain reliever alone for providing relief from a backache or other conditions that are due to spasms.

Which over-the-counter pain reliever is right for you? What to take when.

In some situations, muscle relaxants can be a preferred option for a short period. For example, some people may not be able to take acetaminophen if they have certain conditions, such as liver disease. And those with a history of bleeding ulcers, heart problems, or kidney problems may not be able to take ibuprofen or naproxen. Others may find that their muscle spasms make it difficult to sleep, so the sedation associated with the muscle relaxants could be viewed as a desirable side effect in this case.

When choosing among the many muscle relaxants, your doctor will take into account the severity of your symptoms, other medical conditions you have, and the common side effects muscle relaxants can cause. Those side effects, including dizziness and drowsiness, can be a concern for pilots, drivers, and people who use heavy or dangerous equipment.

Many of the muscle relaxants, including carisoprodol, chlorzoxazone, cyclobenzaprine, metaxalone, methocarbamol, and orphenadrine, are not recommended for use in people 65 years or older because the sedating effects could lead to accidents or falls.

When you first begin one of these drugs, take the first dose at a time when you do not have to be at work or go anywhere, such as in the evening or on a weekend, to see how much sedation you experience. Do not drink any alcohol while taking these medicines. And avoid driving, or operating heavy machines.

For treating back or neck pain from muscle spasms, muscle relaxants are typically used on an as-needed, short-term basis. Although they are sometimes given long-term for treating those conditions, there is little evidence to show that chronic use actually improves symptoms.

If the spasms last longer than a few weeks, you should discuss with your doctor whether you are truly benefiting from the muscle relaxant and whether it should be continued, and if other therapies should be tried.

Cyclobenzaprine is the best studied of the muscle relaxants. In more than 20 studies—most of which involved people with back or neck pain and lasted for two weeks—cyclobenzaprine was consistently more effective than placebo on various measures of pain relief, functional ability, and muscle spasm.

One analysis of 10 studies of people who took cyclobenzaprine compared with people who took a sugar pill (placebo) to treat back or neck pain found that after 10 to 21 days, people with either types of pain who took cyclobenzaprine said their pain was reduced by about one point on 10-point pain or function scale, compared with those who took a placebo.

Carisoprodol and orphenadrine have been studied less, with only four trials for each drug. Both drugs appear to be more effective than placebo for relieving pain due to spasms.

There is not enough good quality research on the other medications—chlorzoxazone, metaxalone, and methocarbamol—to determine how well they relieve pain.

There are few high quality studies that have compared one muscle relaxant against another, so we can't determine whether any one muscle relaxant is a standout. There is also not enough research to know if pills that combine a muscle relaxant with another drug, such as aspirin, codeine, or caffeine, are any more effective than a muscle relaxant alone.

Table 2. Studies done on muscle relaxants

* Key to chart:

++ = more than 10 studies showing benefit

+ = 2-4 studies showing benefit

+/- = inconsistent evidence.

One of the most common side effects of muscle relaxants is sedation. Most people experience it when they take one of these drugs. Below, we list other common side effects as well.

Some muscle relaxants have some serious side effects. For example, there have been rare cases of serious liver damage associated with chlorzoxazone, so this medication should not be prescribed to people with liver disease or hepatitis. The package insert (which can be found here) for each medication lists the side effects, and you can also ask your doctor or pharmacist.

The available research doesn't show any clear differences between the muscle relaxants in the risk of different side effects they pose.

Table 3. Most common side effects of muscle relaxants

Abuse and addiction

Although there are not enough studies to show the comparative risk of abuse or addiction between each of these drugs, almost all reports have been in people taking carisoprodol (Soma and generic). Carisoprodol is the only one of the muscle relaxants that is classified as a controlled substance due to the concern of a high number of reports of nonmedical emergency visits by the Drug Abuse Network and 88 cases of death attributed to carisoprodol in 2007.

There have also been a rising number of reports of misuse or abuse of cyclobenzaprine. From 2004 to 2010, there was a 100 percent increase in the number of emergency room visits associated with the drug.

Age, gender, and race differences

There is not enough relevant evidence from the available studies to determine whether the muscle relaxants have different efficacy or safety profiles in younger or older people, different races, or men and women.

Older people should not take these drugs because they are associated with a higher risk of fractures due to falls. The high risk of falls are likely due to the sedating effects of muscle relaxants and their effect of lowering blood pressure.

We have not chosen any muscle relaxant as a Best Buy because there aren't enough good-quality studies that show the drugs are effective. Plus, they pose serious safety concerns, particularly for elderly people.

If you decide with your doctor to try a muscle relaxant, know that they should be taken for the shortest time possible, not to exceed three weeks in most cases—and maybe less, depending on your pain. Due to the risk of sedation and other side effects, they should be used very cautiously and only with a doctor's close supervision.

In addition to sedation, the most common side effects associated with muscle relaxants to watch out for include weakness or fatigue, dizziness, and dry mouth. Table 4, below, lists important considerations for each muscle relaxant.

We recommend avoiding carisoprodol (Soma) because it is associated with a high risk of abuse and addiction potential not seen with other muscle relaxants.

Table 4. Muscle relaxants: Key points

1. Anonymous. Extended-release cyclobenzaprine (Amrix). Medical Letter on Drugs & Therapeutics. 2007;49:102-3.
2. Bailey DN. Briggs JR. Carisoprodol. An unrecognized drug of abuse. American Journal of Clinical Pathology. 2002;117:396-400.
3. Browning R, Jackson JL, O'Malley PG. Cyclobenzaprine and back pain: A meta-analysis. Arch Intern Med. 2001;161(13):1613-1620.
4. Carette S, Bell MJ, Reynolds WJ, et al. Comparison of amitriptyline, cyclobenzaprine, and placebo in the treatment of fibromyalgia: A randomized, double-blind clinical trial. Arthritis Rheum. 1994;37:32-40.
5. Chou R, Peterson K, Helfand M. Comparative efficacy and safety of skeletal muscle relaxants for spasticity and musculoskeletal conditions: A systematic review. J Pain Symptom Manage. 2004;28:140-75.
6. Chou R. Pharmacological management of low back pain. Drugs. 2010 Mar 5; 70(4):387-402.
7. Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: A joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147(7):478–491.
8. Darwish M, Xie F. Comparison of the Single-Dose Pharmacokinetics of Once-Daily Cyclobenzaprine Extended-Release 30 mg and Cyclobenzaprine Immediate-Release 10 mg Three Times Daily in the Elderly: A randomized, open-label, crossover study. Drugs & Aging. 2009;26:95-101.
9. Owens C, Pugmire B, Salness T, Culbertson V, Force R, Cady P, Steiner J. Abuse potential of carisoprodol: A retrospective review of Idaho Medicaid pharmacy and medical-claims data. Clinical Therapeutics. 2007;29:2222-5.
10. Powers BJ, Cattau EL, Zimmerman HJ. Chlorzoxazone hepatotoxic reactions. An analysis of 21 identified or presumed cases. Arch Intern Med. 1986;146(6):1183-1186.
11. Reeves RR, Carter OS, Pinkofsky HB, Struve FA, Bennett DM. Carisoprodol (soma): Abuse potential and physician unawareness. Journal of Addictive Diseases. 1999;18:51-6.
12. Tofferi JK, Jackson JL, O'Malley PG. Treatment of fibromyalgia with cyclobenzaprine: A meta-analysis. Arthritis Rheum. 2004;51(1):9-13.
13. van Tulder MW, Touray T, Furlan AD, Solway S, Bouter LM. Muscle relaxants for nonspecific low-back pain: A systematic review within the framework of the Cochrane collaboration. Spine. 2003;28:1978-92.
14. Weinman D, Nicastro O, Akala O, and Friedman BW. Parenteral Treatment of Episodic Tension-Type Headache: A Systematic Review. Headache: The Journal of Head and Face Pain. 2014;54: 260–268. doi: 10.1111/head.