Medication Management for Pain Control

By Preetanjali Thakur, BDS, MS

Medications can be helpful in treating orofacial pain conditions like TMD, myofascial pain, neuropathic conditions and headache disorders in addition to other non-pharmacological therapies.

When it comes to managing severe facial pain, especially pain related to your jaw (TMD), medications can have an important role. However, it’s not a one-size-fits-all approach. We need to work together to find the right combination of medications and therapies that give you relief without causing side effects that get in the way of your daily life. It must be a patient centered approach, where you are able to discuss the pros and cons of these drugs, interactions with your existing medications and impact on other medical conditions. It is also imperative to understand that medical management for musculoskeletal conditions is supportive and palliative. Pain tends to be a defining feature of TMD and myofascial pain. Pain can be joint and/or muscle related and may lead to restricted jaw function. Therefore, it is also essential to address contributing factors for the presentation and to improve jaw function.

Some of these non-pharmacological approaches include:

• Awareness of tongue and jaw positioning to reduce bruxism.
• Working with health coaches to learn coping mechanisms.
• Address co-morbid sleep and psychological disorders.
• Working with physical therapist to improve jaw mechanics.

 

Role of Medical Management in Facial Pain Treatment

 

The first step before any treatment options are considered is diagnostic clarification. Your orofacial pain provider will take a comprehensive history, do a clinical exam and consider additional diagnostics like imaging. After diagnostic clarification a treatment plan will be reviewed which may include short term use of medications for acute problems. For chronic pain management long term use of drugs can be considered too. It is important to identify the etiology of these conditions and then render treatment in a timely manner to avoid these pain experiences and conditions to become persistent.

Pain management aims to reduce pain intensity and improve daily function.

Minnesota Head & Neck Pain Clinic relies on evidence-based strategies for multimodal pain TMD treatment. This often includes using interdisciplinary approaches, nonopioid medications, minimally invasive interventional procedures, and alternative therapies to optimize patient outcomes while minimizing the risks associated with long-term prescription use.

We evaluate each patients’ pain medication needs individually. Your pain care team will know your available nonopioid treatment options and understand the best course of action, indications, and associated benefits/complications for each modality.

Care across integrated medical teams is important in patients with chronic facial pain using alternative treatments to opioids. Optimal pain care may be gained through a combined team approach involving your primary care physician, pain management physician, dentist, physical therapist, occupational therapist, and pain coach. The treating clinician’s role includes integrating all related team members; the role of the prescribing clinician is to make the best pharmacologic decisions.

This coordinated approach supports the patient’s progress and helps prevent the risks associated with opioid medications.

 

“Multiple classes of nonopioid medications are routinely used to treat pain, including over-the-counter and prescribed nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, steroids, antidepressants, anticonvulsants, and topical medications.” – Alternatives to Opioids for Managing Pain

 

Common Types of Medications Used for Pain Management

Types of Medication

NSAIDs:

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) are commonly used to manage pain associated with TMD (Temporomandibular Disorder). Evidence suggests that NSAIDS are the first line of drugs for short term.

Here’s how NSAIDs medications work:

NSAIDs block the production of inflammatory substances in the body that trigger pain, they specifically act on COX enzymes. By blocking the release of prostaglandins, they help to reduce discomfort and pain in the jaw joint and surrounding muscles, which can help alleviate tenderness and discomfort.

Common NSAIDs used for TMD pain include:

• Ibuprofen (Advil, Motrin)
• Naproxen (Aleve)
• Diclofenac gel 1% (topical application)

 

Acetaminophen (paracetamol):

Acetaminophen is one of the most commonly used analgesic agents for alleviating acute and chronic pain. Due to its safety, acetaminophen is prescribed for patients in whom non-steroidal anti-inflammatory drugs (NSAIDs) are contraindicated, such as those with gastric ulcers and bronchial asthma, pregnant women, nursing mothers, and children. Acetaminophen works by blocking pain signals in the brain, which can help reduce the perception of pain. It may be prescribed to decrease enzyme production in the brain, thus blocking the further transmission of the pain nerve impulses.

 

Corticosteroids:

Corticosteroids are typically used for short-term relief due to potential side effects, such as increased blood sugar levels and weakened immune system. An orofacial pain specialist might recommend corticosteroids for pain management in the following situations:

 

• Severe Inflammation: If you have significant inflammation in your jaw joint or surrounding tissues, corticosteroids can help reduce inflammation and pain.
• Acute Flare-ups: Corticosteroids can be used to manage acute flare-ups of TMJ pain, especially if other treatments have not been effective there is extremely limited range of motion.
• Underlying connective tissue disorder: Short course steroid pack can be considered to address inflammatory arthritic conditions.

 

Corticosteroids can be used both topically and orally at the Minneosta Head and Neck Pain clinic. We do consider TMJ iontophoresis with dexamethasone for topical application of steroids in TMJs. This involves a series of treatment and is done by a trained physical therapist. If symptoms persist TMJ injections can be considered as well, these may be done by orofacial pain specialist’s, interventional radiologists, or oral and maxillofacial surgeons.

 

Muscle relaxants:

 

For treatment of muscle pain in myofascial pain condition, muscle relaxants can be prescribed for pain relief. Cyclobenzaprine is commonly used. A recent meta-analysis concluded that cyclobenzaprine had a positive effect on TMD muscle pain in the short term through its effect over local spasms and associated acute pain.

Other muscle relaxants which can be used include:

• Methocarbamol
• Baclofen
• Orphenadrine, etc.

Topical clonazepam is used for certain conditions like Burning Mouth Syndrome. In certain situations, medications like diazepam and clonazepam can be considered. However, BZD’s have higher risk of dependency than some other centrally acting muscle relaxants.

 

Antidepressants:

 

Serotonin and norepinephrine reuptake inhibitors (SNRIs) and tricyclic antidepressants are the most common classes of antidepressants used to manage chronic neuropathic pain. Duloxetine, tricyclic antidepressants (TCAs), including amitriptyline, are medications sometimes prescribed for additional healthcare needs such as fibromyalgia and chronic musculoskeletal pain. Additionally, antidepressants may be recommended as a prophylactic treatment for migraine and tension-type headaches. Both serotonin and SNRIs can be more effective in patients with depressive symptoms and pain as comorbidity than in those patients with pain alone. ^[4]

 

Anticonvulsants:

 

Anticonvulsants are sodium and calcium channel blockers and are typically treatment of choice for neuropathic pain conditions and neuralgia. According to current medical information, the most commonly prescribed anticonvulsants for facial pain, specifically for trigeminal neuralgia, are carbamazepine (Tegretol) and oxcarbazepine (Trileptal), considered the first-line treatment options for this condition; other potential anticonvulsants include gabapentin (Neurontin), pregabalin (Lyrica), lamotrigine (Lamictal), and phenytoin (Dilantin) which may be used depending on individual needs and response to treatment. ^[1]

 

Local anesthetic:

 

Topical lidocaine can be used for temporary relief of discomfort. These can be used with medication stent to target the specific, local site. These are most commonly used for peripheral nerve injuries. At times a combination of topical lidocaine can be used with capsaicin to target several pain fibers. Compound topical medications can be prescribed by the treating provider to treat complex neuropathic and orofacial pain conditions. Long-acting anesthetic agents like 2% Bupivacaine can be used as trigger point injections for targeted masticatory and cervical muscle spasm. Trigger point injections provide short term relief and are more effective with active jaw stretching and physical therapy modalities. At times trigger point injections can also be used for diagnostic clarification. Appasamy M, Lam C, Alm J, Chadwick AL. Trigger Point Injections. ^[2]

 

Botulinum toxin:

 

Botulinum toxin (BTX) has become a popular treatment for TMD and jaw in recent years. BTX is a neurotoxin produced by a bacteria. Since the late 1970s, botulinum toxin serotypes A and B (BTX-A and BTX-B) have been used to treat neuromuscular diseases such as cervical dystonia. This neurotoxin acts on neurotransmitter and results in diminished muscular activity. Because many TMDs are linked to clenching, bruxism, or parafunctional mandibular actions, muscle activity inhibition may help in addition to mainstays of TMD management.

 

In addition, BTX may have a centrally mediated action as well. Despite showing benefits, consensus on the therapeutic benefit of BTX in the management of myofascial TMD pain is lacking, needing more high-quality research studies including RCT’s. ^[3] For jaw and neck pain, Botox (botulinum toxin)can be injected into the affected muscles around the jaw and neck to alleviate pain caused by muscle tension or spasms.  

Peripheral nerve blocks:

  They can be used as diagnostic and therapeutic tools in managing chronic pain. Trigeminal neuropathic pain (TNP) and temporomandibular disorders (TMD) have fundamentally different etiologies. It’s important to rely on the medication advice of you pain provider, especially in the case of chronic facial nerve pain.  

Trigger point injections:

  Trigger point injections, are a local anesthetic injected into specific trigger points in the muscles to alleviate pain. They are a therapeutic option for treating myofascial pain syndrome.  

Transcutaneous Electrical Nerve Stimulation:

TENS Therapy for TMJ disorders reduces Muscles relax. It does this by increasing muscle elasticity, which assists in helping spasms subside. Meaning, the temporomandibular joint takes the desired position when these muscles are deterred from returning to their spasmodic state. In this way, TENS can reduce the need for pain relievers in cases of jaw pain.  

Medication as Part of an Integrative Pain Management Approach

Medication therapy is best with a multifaceted treatment plan that is led by a professional pain provider. Some pain relief interventions may be as simple as breathing exercises, meditation, electrical stimulation, and other relaxation exercises to help control pain. You may find an Over-the-counter (OTC) medication that provides temporary relief. If it persists or becomes more intense, seek an integrative approach and overall effective pain treatment plan. Write down all OTC’s you have used to try to reduce your pain and bring to your pain assessment appointment. By helping to manage pain, medications can contribute to overall well-being, reducing stress and anxiety that often exacerbate chronic pain.

 

“Talk with the health care providers you see for chronic pain. Tell them about the product or practice you’re considering and ask any questions you may have. They may be able to advise you on its safety, use, and likely effectiveness. If you’re considering dietary supplements, keep in mind that they can cause health problems if not used correctly, and some may interact with prescription or nonprescription medications or other dietary supplements. Your health care provider can advise you.” – Chronic Pain and Complementary Health Approaches

  While medications like acetaminophen or ibuprofen may be helpful for the nociceptive component of TMD pain, they are often not effective for the neuropathic component. Similar to trigeminal neuralgia, the neuropathic pain associated with TMD may be better managed with medications traditionally used for other conditions, such as antiepileptic drugs (AEDs) or antidepressants (ADs).  

Nonopioid Analgesic Agent	Low-Level Pain	Moderate Pain	High-Level Pain
Acetaminophen (Tylenol)	✔	✔	❌
Nonsteroidal Anti-inflammatory Drugs (NSAIDs) (e.g., Ibuprofen (Advil, Motrin), Naproxen (Aleve))	✔	✔	May be helpful depending on severity and type of pain, consult a healthcare professional.

 

The A checkmark (✔) indicates the agent is suitable for that pain level. A red “❌” indicates acetaminophen isn’t generally used for high-level pain.

“Prior to working with MN head and neck pain clinic I was in almost constant pain and discomfort that impacted most areas of my life. Today my pain is more than manageable and my overall quality of life has greatly improved.” – Patient Review

 

SUMMARY: A Safe & Effective Approach to Medication Management

A pain medication may be determined “safe” if used appropriately. Read all medicine labels and be sure to follow your pain providers instructions carefully. Our practitioners pay close attention to patient’s symptoms, follow through, and complaints to provide the best healthcare possible and avoid possible adverse systemic effects. Our team of orofacial pain providers are board certified and offer proven experience prescribing a wide variety of medication interventions. We offer several locations in the Twin Cities and across Minnesota.

About the author

Preetanjali Thakur, BDS, MS has a Masters in Dental Science and extensive experience that supports her expertise in management of acute and chronic pain disorder treatments. She believes in focusing on self-care, identifying and addressing the contributing factors and working with a team. When needed, Dr. Thakur uses interventional approaches like trigger point injections, and Botox therapy.   Resources: [1] Taimur Sher, MBBS, MD, et al., “Trigeminal neuralgia,” https://www.mayoclinic.org/diseases-conditions/trigeminal-neuralgia/diagnosis-treatment/drc-20353347 [2] Malathy Appasamy, et al., “Trigger Point Injections,” May 2022, https://pubmed.ncbi.nlm.nih.gov/35526973/ [3] Robert Delcanho, et al., “Botulinum Toxin for Treating Temporomandibular Disorders: What is the Evidence?,” June 2022, https://www.sciencedirect.com/science/article/abs/pii/S0266435620300620. [4] Daniel A. Queremel Milani; Donald D. Davis, “Pain Management Medications,” July 2023, https://www.ncbi.nlm.nih.gov/books/NBK560692/ DISCLAIMER: “The information on this site should not be used as a substitute for personal professional medical care or advice. Contact a health care provider if you have questions about your health.