Treatment algorithm

Your Organisational Guidance

ebpracticenet urges you to prioritise the following organisational guidance:

Multimodale aanpak van chronische primaire pijn (CPP) in de eerstelijnszorgPublished by: Werkgroep Ontwikkeling Richtlijnen Eerste Lijn (Worel)Last published: 2024Prise en charge multimodale de la douleur chronique primaire (DCP) en première ligne de soinsPublished by: Groupe de Travail Développement de recommmandations de première ligneLast published: 2024

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

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myofascial pain

1st line – physiotherapy

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myofascial pain
1st line – 

physiotherapy

All patients with myofascial pain should be treated primarily with physiotherapy, including posture training, stretching exercises, and active range of motion exercises. Exercise programmes should be tailored to the patient’s physical ability and lifestyle.[50][51][54] Patients will probably need to meet several times weekly with a physiotherapist initially for instruction in techniques, with requirements for home practice between appointments. The goal of the therapy is for the patient to develop a home programme that they may continue independently twice daily on a long-term basis.

Consider – analgesia

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myofascial pain
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analgesia

Additional treatment recommended for SOME patients in selected patient group

Non-steroidal anti-inflammatory drugs (NSAIDs) are recommended first line if analgesia is needed to supplement physiotherapy in patients with myofascial pain, particularly during exacerbations of symptoms.

In patients with myofascial pain who do not obtain satisfactory pain relief from NSAIDs, an alternative analgesic may be used instead (i.e., paracetamol). Tramadol or codeine may be used (at the lowest effective dose) for a limited duration if benefits are anticipated to outweigh risks to the patient.[42] Centers for Disease Control and Prevention guidance for prescribing opioids for chronic pain addresses patient discussions, setting treatment goals, initiation, drug selection and dosages, follow-up, continuation, risk assessment, addressing potential harms, and discontinuation. Short-acting and immediate-release agents are favoured.[42]

Primary options

ibuprofen: 300-400 mg orally every 6-8 hours when required, maximum 2400 mg/day

OR

naproxen: 250-500 mg orally twice daily when required, maximum 1250 mg/day

OR

diclofenac sodium: 100 mg orally (extended-release) once daily when required

OR

diclofenac potassium: 50 mg orally (immediate-release) two or three times daily when required

Secondary options

paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

-- AND / OR --

tramadol: 50-100 mg orally (immediate-release) every 4-6 hours when required, maximum 400 mg/day

or

codeine phosphate: 30-60 mg orally every 4 hours when required, maximum 240 mg/day

Consider – occupational therapy

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myofascial pain
Consider – 

occupational therapy

Additional treatment recommended for SOME patients in selected patient group

Patients whose pain impacts on daily living, work, or social activities, or mood should be evaluated by an occupational therapist and offered pain management training and work modifications.

Consider – pain management psychology

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myofascial pain
Consider – 

pain management psychology

Additional treatment recommended for SOME patients in selected patient group

Psychological therapy for pain management skills should be provided for all patients whose myofascial pain has a negative impact on daily activities or mood. Psychological therapies may include cognitive behavioural therapy (CBT; including internet-delivered CBT), acceptance and commitment therapy, behavioural therapy, relaxation therapy, stress management, and coping skills.[51][52][55][56][57][58] [ Cochrane Clinical Answers logo ]

Consider – muscle relaxant

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myofascial pain
Consider – 

muscle relaxant

Additional treatment recommended for SOME patients in selected patient group

Patients with severe myofascial pain that does not respond to physiotherapy and NSAIDs may benefit from additional use of a muscle relaxant such as tizanidine.[62]

Primary options

tizanidine: 1-2 mg orally once daily at bedtime initially, increase gradually according to response, maximum 24 mg/day given in 2-3 divided doses

Consider – trigger-point injections, acupuncture, and/or dry needling

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myofascial pain
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trigger-point injections, acupuncture, and/or dry needling

Additional treatment recommended for SOME patients in selected patient group

Trigger-point injections may be used as an option for treating myofascial pain in some patients; systematic reviews that include myofascial pain studies indicate that outcomes are similar regardless of type of injectate used.[59][60]

Techniques such as acupuncture and dry needling are useful for release of trigger points, and may be used in the wider context of a rehabilitative/pain management approach.[61]

musculoskeletal pain

1st line – physiotherapy

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musculoskeletal pain
1st line – 

physiotherapy

Physiotherapy is the cornerstone of treatment for musculoskeletal (mechanical) pain. All patients should be considered for weight management (as appropriate) and physiotherapy with or without additional pool hydrotherapy as available. Exercise programmes should be tailored to the patient’s physical ability and lifestyle.[50][51][54]

Consider – paracetamol and/or non-steroidal anti-inflammatory drugs (NSAIDs)

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musculoskeletal pain
Consider – 

paracetamol and/or non-steroidal anti-inflammatory drugs (NSAIDs)

Additional treatment recommended for SOME patients in selected patient group

Paracetamol and NSAIDs, alone or in combination, can be used for exacerbations of musculoskeletal pain.

A comparison of gastrointestinal risk among different NSAIDs and strategies for their selection based upon comorbidities are provided by a consensus statement from the American College of Clinical Pharmacy.[97]

See also Osteoarthritis and Musculoskeletal lower back pain.

Primary options

paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

-- AND / OR --

ibuprofen: 300-400 mg orally every 6-8 hours when required, maximum 2400 mg/day

or

naproxen: 250-500 mg orally twice daily when required, maximum 1250 mg/day

or

diclofenac sodium: 100 mg orally (extended-release) once daily when required

or

diclofenac potassium: 50 mg orally (immediate-release) two or three times daily when required

Consider – occupational therapy

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musculoskeletal pain
Consider – 

occupational therapy

Additional treatment recommended for SOME patients in selected patient group

Patients whose pain impacts on daily living, work, or social activities, or mood should be evaluated by an occupational therapist and offered pain management training and work modifications.

Consider – pain management psychology

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musculoskeletal pain
Consider – 

pain management psychology

Additional treatment recommended for SOME patients in selected patient group

Psychological therapy for pain management skills should be provided for patients whose musculoskeletal pain has a negative impact on daily activities or mood. Psychological therapies may include cognitive behavioural therapy (CBT; including internet-delivered CBT), acceptance and commitment therapy, behavioural therapy, relaxation therapy, stress management, and coping skills.[51][52][55][56][57][58] [ Cochrane Clinical Answers logo ]

Consider – specialist referral for patients with rheumatoid arthritis (RA)

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musculoskeletal pain
Consider – 

specialist referral for patients with rheumatoid arthritis (RA)

Additional treatment recommended for SOME patients in selected patient group

All patients with RA should be initially assessed by a rheumatologist and offered treatment with disease-modifying antirheumatic drugs (DMARDs). Patients with mild to moderate disease are usually started on a single DMARD, unless there are specific contraindications.

Patients who do not obtain sufficient benefit from conventional synthetic DMARDs may be started on a biological agent or a targeted synthetic DMARD, either alone or combined with a conventional synthetic DMARD.[64]

See Rheumatoid arthritis. 

neuropathic pain

1st line – pharmacotherapy

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neuropathic pain
1st line – 

pharmacotherapy

Medicines are used as first-line treatment for neuropathic pain, with a goal of reducing the distressing symptoms.

Membrane-stabilising anticonvulsants (e.g., gabapentin, pregabalin) and tricyclic antidepressants (TCAs; e.g., amitriptyline) are effective.[66][67][68][69][70]

The serotonin-noradrenaline reuptake inhibitor (SNRI) duloxetine may be beneficial in patients unable to tolerate TCAs.

Second-line therapy includes topical capsaicin (cream or patch) or a lidocaine patch. Evidence for low-dose capsaicin (i.e., 0.025% or 0.075%) is poor, but it may be considered in some cases.[72]

Primary options

gabapentin: 300 mg orally once daily on day one, followed by 300 mg twice daily on day 2, followed by 300 mg three times daily on day 3, then titrate dose slowly according to response, maximum 3600 mg/day

OR

pregabalin: 75-150 mg orally twice daily, maximum 300 mg/day

OR

amitriptyline: 10 mg orally once daily at night, then titrate dose slowly according to response, maximum 50 mg once daily at night

OR

duloxetine: 60 mg orally once or twice daily

Secondary options

capsaicin topical: (0.025% or 0.075% cream) apply to the affected area(s) three to four times daily; (8% transdermal patch) apply 1-4 patches to affected area and remove after 30-60 minutes, may repeat no more frequently than every 3 months

OR

lidocaine topical: (5% transdermal patch) apply up to 3 patches at a time for up to 12 hours/day

Consider – physiotherapy

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neuropathic pain
Consider – 

physiotherapy

Additional treatment recommended for SOME patients in selected patient group

All patients with neuropathic pain who have physical difficulty with daily living, work, or social activities should be offered physiotherapy, including posture training, stretching exercises, and active range of motion exercises.[73] Exercise programmes should be tailored to the patient’s physical ability and lifestyle.[50][51][54]

Consider – occupational therapy

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neuropathic pain
Consider – 

occupational therapy

Additional treatment recommended for SOME patients in selected patient group

Patients whose pain impacts on daily living, work, or social activities, or mood should be evaluated by an occupational therapist and offered pain management training and work modifications.

Consider – pain management psychology

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neuropathic pain
Consider – 

pain management psychology

Additional treatment recommended for SOME patients in selected patient group

Psychological therapy for pain management skills should be provided for all patients whose neuropathic pain has a negative impact on daily activities or mood. Psychological therapies may include cognitive behavioural therapy (CBT; including internet-delivered CBT), acceptance and commitment therapy, behavioural therapy, relaxation therapy, stress management, and coping skills.[51][52][55][56][57][58] [ Cochrane Clinical Answers logo ]

Consider – neurostimulation

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neuropathic pain
Consider – 

neurostimulation

Additional treatment recommended for SOME patients in selected patient group

Non-invasive and invasive neurostimulation may be used to treat chronic neuropathic pain. Techniques with some evidence of benefit include spinal cord stimulation, epidural motor cortex stimulation, repetitive transcranial magnetic stimulation, and transcranial direct electrical stimulation.[74][75][76][77] Transcutaneous electrical nerve stimulation (TENS) is also sometimes used to treat neuropathic pain but it is unclear whether it is effective, due to the low quality of the evidence.[78] There is insufficient evidence to support or refute the use of acupuncture for treating neuropathic pain.[79]

Consider – referral for specialist treatment

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neuropathic pain
Consider – 

referral for specialist treatment

Additional treatment recommended for SOME patients in selected patient group

Referral for specialist treatment may be necessary for some patients for neuropathic pain: for example, those with diabetic neuropathy, postherpetic neuralgia, or complex regional pain syndrome (CRPS).

Neuropathic pain due to diabetic neuropathy requires glucose control. Consultant referral may be required. See Diabetic neuropathy. 

Postherpetic neuralgia occurs in about 30% of patients with herpes zoster, and the risk may be minimised by early treatment with antiviral agents.[19] Patients with postherpetic neuralgia and eye involvement should be referred to an ophthalmologist. See Herpes zoster infection. 

CRPS is managed with aggressive physiotherapy and drug therapy. Patients with CRPS should be referred early to a pain clinic. See Complex regional pain syndrome. 

fibromyalgia

1st line – multidisciplinary treatment

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fibromyalgia
1st line – 

multidisciplinary treatment

Due to the multi-symptom nature of fibromyalgia and high disability in this population, the majority of fibromyalgia patients should have comprehensive, multidisciplinary treatment, with a predominant aim of improving health-related quality of life.[80] Referral to a psychologist is appropriate at initial diagnosis.

Non-pharmacological therapies with some evidence of benefit include exercise therapy, hydrotherapy, psychological pain management skills (e.g., cognitive behavioural therapy), and occupational therapy.[80][81][82][83][84] [ Cochrane Clinical Answers logo ] Exercise programmes should be tailored to the patient’s physical ability and lifestyle.[50][51][54]

Pharmacological therapies with some evidence of benefit include tricyclic antidepressants (TCAs), serotonin-noradrenaline reuptake inhibitors (SNRIs), and tramadol. NSAIDs and selective serotonin-reuptake inhibitors (SSRIs) have not been shown to be effective for treating fibromyalgia pain. Strong opioids should not be used because of the high risk of adverse effects.[42][80] 

See Fibromyalgia. 

chronic headache

1st line – individualised treatment

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chronic headache
1st line – 

individualised treatment

Ensure that the headache diagnosis is accurate before starting treatment.[2]

Post-traumatic headache (i.e., headache from trauma or injury to the head and/or neck) is treated in the same way as tension-type headache.

Cluster headache: specialist referral is often required, to discuss treatment options. Chronic cluster headaches are primarily managed with preventive therapy (e.g., calcium-channel blockers). Rescue therapy (e.g., a subcutaneous triptan or oxygen) may be tried during the cluster headache episode.

Migraine headache: avoidance of triggers (e.g., alcohol, caffeine) is important; this can be facilitated by keeping a migraine diary. Drug treatment for symptom relief (e.g., NSAIDs, paracetamol, triptan) should be started as soon as the patient recognises that a typical migraine attack is beginning, even if symptoms are mild. Preventive treatments (e.g., anticonvulsants, beta-blockers, antidepressants, calcium-channel blockers, or calcitonin gene-related peptide antagonists) should be considered for people with disabling, frequent migraine attacks, when acute treatments are ineffective or contraindicated, or when attacks lead to neurological sequelae.

Drug overuse headache: treated with withdrawal of the overused drug, supported by symptomatic management, preventive treatment for the primary headache disorder, and patient and family education.

See Migraine headache in adults, Cluster headache, Tension-type headache, and Medication overuse headache.

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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