Treatment of Myofascial Pain Syndrome

First-Line Treatments

Manual physical therapy techniques should be offered as first-line treatment for patients with myofascial pain syndrome who present with pelvic floor tenderness or muscle trigger points 1
The American Urological Association recommends manual physical therapy techniques, including maneuvers that resolve muscular trigger points, techniques that lengthen muscle contractures, and release of painful scars and connective tissue restrictions, as first-line treatment for myofascial pain syndrome 1
Low-resistance exercise is recommended to improve joint stability by increasing muscle tone, according to the Genetics in Medicine guidelines 2
Physical therapy for myofascial release is often necessary to facilitate participation in exercise programs, as suggested by the Genetics in Medicine guidelines 2

The National Comprehensive Cancer Network recommends NSAIDs for symptomatic relief of myofascial pain 3, 4
Tricyclic antidepressants and serotonin-norepinephrine reuptake inhibitors (SNRIs) may be beneficial for myofascial pain, according to the National Comprehensive Cancer Network guidelines 4
Anticonvulsants (gabapentin, pregabalin) can be considered for persistent pain, as recommended by the National Comprehensive Cancer Network 4

Topical treatments, including lidocaine patches, capsaicin, and diclofenac patches, may provide relief for myofascial pain, according to the National Comprehensive Cancer Network guidelines 5, 6
Heat, cold packs, and medicated creams/ointments are recommended for myofascial pain, as suggested by the National Comprehensive Cancer Network guidelines 5, 6

Cognitive behavioral therapy may benefit some patients with myofascial pain, according to the Annals of the Rheumatic Diseases guidelines 3
Relaxation techniques, breathing exercises, and other behavioral therapies can be useful for myofascial pain, as recommended by the National Comprehensive Cancer Network guidelines 4
Psychosocial support and education should be provided for patients with myofascial pain, according to the National Comprehensive Cancer Network guidelines 4

The American College of Rheumatology recommends that strong opioids should not be used for myofascial pain management, as stated by the Annals of the Rheumatic Diseases 7
The American College of Rheumatology also suggests that corticosteroids have no role in isolated myofascial pain syndrome, unless concomitant joint pathology exists, as stated by the Annals of the Rheumatic Diseases 7

The European League Against Rheumatism recommends that peripheral somatic nerve blocks should not be used for long-term treatment of myofascial pain, although the exact citation is not provided, a similar recommendation is made by the Annals of the Rheumatic Diseases regarding opioid use 7

The National Comprehensive Cancer Network (NCCN) recommends 5 % lidocaine patches applied daily to painful sites, providing localized analgesia with minimal systemic absorption. Strength of evidence: not specified. 12
The NCCN recommends diclofenac patches (180 mg once or twice daily) or diclofenac gel applied three times daily for topical anti‑inflammatory relief. Strength of evidence: not specified. 12

For patients with persistent myofascial pain, the NCCN suggests tricyclic antidepressants (e.g., nortriptyline 10–25 mg nightly, titrated to 50–150 mg) or serotonin‑norepinephrine reuptake inhibitors (e.g., duloxetine 30–60 mg daily, titrated to 60–120 mg). Strength of evidence: not specified. 12
The NCCN advises the use of anticonvulsants such as gabapentin (starting 100–300 mg nightly, titrated up to 900–3600 mg daily in divided doses) or pregabalin (starting 50 mg three times daily, titrated to 100 mg three times daily) for refractory pain. Strength of evidence: not specified. 12

Strong opioids should be avoided in the management of myofascial pain syndrome, as evidence indicates lack of benefit and potential harm. (Annals of the Rheumatic Diseases, 2008) Strength of evidence: not specified. 13
Systemic corticosteroids have no role in isolated myofascial pain syndrome unless there is concurrent joint pathology. (Annals of the Rheumatic Diseases, 2008) Strength of evidence: not specified. 13

Cognitive‑behavioral therapy can improve outcomes, particularly when psychosocial factors contribute to chronic pain, according to the NCCN. Strength of evidence: not specified. 12
Relaxation techniques and breathing exercises are recommended as supportive adjuncts to enhance pain control (National Comprehensive Cancer Network). Strength of evidence: not specified. 12