Here is the order in which I recommend adding pain medications in cases of fibromyalgia. It may take six weeks to see a medication's full effect, but usually you'll have a good sense of whether it is going to help by three weeks of use.
Though it may take a high dose of a single medication (which may cause unacceptable side effects) to be effective, often combining a low dose of several medications will allow effectiveness without the side effects.
Do not combine medications within a single group below, but rather add one from each group as you go along (and review with your physician to ensure you are using them correctly).
• Begin with a combination of both Skelaxin (metaxalone) — a nonsedating muscle relaxant that helps in about half of those with fibromyalgia; and Ultram (tramadol) — a medication that raises both serotonin and endorphins. If pain persists or side effects prevent the medications use, I then add one medication at a time from the next group (and continue to each subsequent group in the list).
• GABA-stimulating medications: Neurontin (gabapentin) or Gabitril (tiagabine).
• Serotonin and norepinephrine raising medications: Cymbalta (duloxetine), Effexor (venlefaxine), or Savella (Minalcipran).
• Medication with a GABA structure: Lyrica (pregabalin).
• Tricyclic antidepressants (the first two are especially helpful for nerve/burning pain or pelvic pain syndromes, especially when combined with Neurontin or Lyrica): Elavil (amitriptyline), Doxepin (sinequan) — use if the Elavil is too sedating or causes other problematic side effects, or Flexeril (cyclobenzaprine).
• NMDA antagonists: Klonopin (clonazepam) — addictive like valium and helpful at bedtime for restless leg syndrome or severe muscle pain that interferes with sleep, or Namenda (memantine).
• Codeine/narcotic family medications. These can be helpful but can also be addictive and therefore I prefer using the other medications discussed. Nonetheless, these medications are sometimes necessary in a small percent of fibromyalgia patients, and I believe taking them is much less toxic for patients than being in severe pain.
• Other medications that can help fibromyalgia pain (though usually not needed): Zanaflex, Topamax, Permex, and Celebrex.
I have personally treated more than 3,000 patients with fibromyalgia and other chronic pain conditions. I can count on my fingers how many were not able to get adequate pain relief.
This has also been the experience of many other pain specialists that combine natural and prescription pain therapies while using techniques to eliminate trigger points and the underlying causes of muscle pain.
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