Pharmacologic and Non-Pharmacologic Management
What you must know
Match treatment to diagnosis and mechanism. NSAIDs for acute inflammatory and musculoskeletal pain (with GI, renal, and cardiovascular cautions). Muscle relaxants and benzodiazepines for short-term muscle pain, with dependence caution. Tricyclics (nortriptyline, amitriptyline) for chronic and neuropathic pain. Gabapentinoids for neuropathic pain. Carbamazepine for trigeminal neuralgia. Triptans and oxygen for cluster headache; triptans and NSAIDs for migraine. Opioids are reserved and generally discouraged for chronic orofacial pain.
Non-pharmacologic care
Education and self-management, jaw behavior modification, physical therapy, cognitive behavioral therapy, relaxation and sleep hygiene, and occlusal appliances for selected patients. Multidisciplinary care is often required.
Traps
Do not use antibiotics for TMD or for pain without infection. Do not use long-term benzodiazepines for chronic pain. Do not use triptans in patients with uncontrolled cardiovascular disease or within 24 hours of ergot use. Do not assume an occlusal appliance is curative - evidence supports symptom reduction in selected patients. Watch for medication-overuse headache with frequent acute analgesics.
Worked example
A patient with chronic masticatory myalgia and poor sleep is started on a short NSAID course and a muscle relaxant at bedtime, along with education and physical therapy. Long-term opioid therapy is not appropriate; if pain persists, a tricyclic and CBT are more appropriate next steps.
Rule of thumb
Acute inflammatory pain → NSAID; neuropathic pain → gabapentinoid or tricyclic; neuralgia → carbamazepine; chronic pain → education, behavior change, and multidisciplinary care.