Medications

For many people, short-term use of over-the-counter pain medications or nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, may provide temporary relief from jaw and muscle discomfort.

If pain persists, your medical provider can prescribe stronger pain or anti-inflammatory medications, muscle relaxants, or antidepressants that can help ease pain and other symptoms. Many medications originally approved by the FDA for other conditions (e.g. depression, seizures) also work on the same nerves causing pain and can help ease your pain. It’s important to note, there are no drugs specifically labeled by FDA for temporomandibular disorders.

Different subgroups of people with TMJ disorders respond differently to treatment. Just because another person with a TMJ disorder experienced a positive or negative effect with a particular medication does not mean that you will have the same result. For now, we don’t have good evidence to say who will or will not positively respond to a certain medication – or who will experience intolerable side effects. One can only find out through a trial of that medication.

It’s important to work closely with your primary care physician so that they can monitor the effects of these medications and advise on side effects and drug interactions.

How to Report a Problem with Medication

Should you be experiencing any type of issue with a medication, it is important that you report these issues here.

Oral Medication

Nonsteroidal anti-inflammatory drugs (NSAIDs)

NSAIDs are commonly used to relieve the pain and inflammation in the TMJ and muscles of the jaw, face, and neck.

Examples: aspirin, celecoxib (Celebrex), diclofenac (Voltaren), ibuprofen (Motrin, Advil), naproxen (Aleve)

Evidence: NSAIDs may help with acute, localized TMJ inflammation, but they might not be much better than placebo in chronic TMJ pain. More studies for NSAID use for TMJ-related pain are needed.

Caution: Though many are available over the counter without a prescription, NSAIDs are generally not recommended for long-term use as they can cause gastric ulcers, affect kidney function, heart function and blood clotting. Some medications also may adversely interact with NSAIDs, including lithium, methotrexate, ACE inhibitors, and loop diuretics (medicines that increase urine flow).

Corticosteroids

Corticosteroids are powerful anti-inflammatory medications, which typically work better than NSAIDs, but come with greater risks.

Examples: prednisone, dexamethasone

Evidence: There is good evidence that corticosteroids can help with TMJ pain over a period of 4–6 weeks, but…

Caution: …there are some significant side effects. Corticosteroids are produced naturally in the adrenal glands, but high levels of synthetic corticosteroids can backfire, increasing the risk for adrenal damage, hypertension (high blood pressure), electrolyte abnormalities, diminished bone resorption, soft tissue atrophy (degeneration), and impaired immune defenses. As you can imagine, corticosteroids are rarely the first line of defense for chronic TMJ pain, and even then only prescribed for short-term use.

Opioids

Anyone who has ever undergone any kind of surgery is in little doubt about the relief opioids can provide from pain.

Examples: fentanyl (Duragesic), oxycodone (OxyContin, Percoset), hydrocodone (Vicodin), codeine, morphine

Evidence: One randomized trial with 80 subjects provided moderate evidence that a combination analgesic product (NSAID and low-dose codeine) delivered relief from pain associated with TMJ (Shaheed et al., 2019). A recent review identified placebo-controlled studies that reported improved outcomes with morphine and fentanyl for TMJ arthrocentesis (NAM 5-20). Currently, while there are a number of studies showing benefits from opioids during the short period (i.e. weeks to months), there is little data informing us about the long term benefits of opioids in chronic pain. We need much more research on this topic, particularly in TMJ disorders.

Caution: Opioids are associated with some side effects (constipation, nausea, dizziness, fatigue, slowed breathing, etc.), and they can also cause and exacerbate sedation from central nervous system depressants, such as alcohol or benzodiazepines. However, the main clinical concern with opioid treatment is the potential for addiction. While the general risk of addiction is low, some people are at greater risk depending on their family and personal history, and medical and psychological diagnoses. The use of long-term opioids in chronic pain remains controversial and best discussed with your clinician.

Antidepressants

Antidepressants can be prescribed for chronic TMJ pain, based on both known efficacy in neuropathic and musculoskeletal pains, including fibromyalgia, and their beneficial effects on comorbid depression and sleep disturbance.

Examples:

tricyclic antidepressants (TCAs; amitriptyline, nortriptyline (Pamelor), desipramine (Nopramin))
selective serotonin reuptake inhibitors (SSRIs; citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac), paroxetine (Paxil, Pexeva) sertraline (Zoloft))
serotonin-norepinephrine reuptake inhibitors (SNRIs; desvenlafaxine (Pristiq), duloxetine (Cymbalta, Irenka), venlafaxine (Effexor), milnacipran (Svaella)

Evidence: Well-controlled clinical trials are still needed to assess the potential benefits of antidepressants in TMJ patients. TCAs and SNRIs are generally found to have better efficacy in chronic pain than SSRIs.

Caution: Though potentially effective, TCAs carry some side effects, including constipation, urinary retention, dizziness, low blood pressure when standing, and sedation. TCAs are contraindicated for cardiac and elderly patients. SSRIs and SNRIs have similar side effects, such as dizziness, nausea, dry mouth, insomnia, sweating, headache, tiredness, anxiety and sexual dysfunction. SSRIs also have the potential to cause increased bruxism and exacerbate pain. If you notice increased teeth grinding/bruxing when taking antidepressants, talk to your doctor who prescribed the medication as it could be caused by the antidepressant.

Muscle Relaxants

Much of the pain TMJ sufferers experience is thought to be caused by tight, overactive muscles in the jaw and face. Muscle relaxants act as a central nervous system depressants and have sedative and musculoskeletal relaxant properties.

Examples: cyclobenzaprine (Flexeril), carisoprodol (Soma), metaxalone (Skelaxin), methocarbamol (Robaxin), orphenadrine (Norflex), tizanidine (Zanaflex)

Evidence: Some studies show muscle relaxants relieving muscle spasms in cervical and lumbar pain, but more research is needed to explain the direct effects of muscle relaxants on muscle-related TMJ pain. There is little data to inform us on the long-term use of muscle relaxants in chronic pain in general and specifically TMJ pain.

Caution: The primary side effect with muscle relaxants is drowsiness, so it’s recommended that muscle relaxants be taken before bedtime and not before driving. Other side effects include dizziness, headache, nervousness, and low blood pressure when standing. Muscle relaxants can also interact with MAOIs (monoamine oxidase inhibitors, a class of antidepressants) and tramadol (an opioid), and they should not be taken in patients with hyperthyroidism, congestive heart failure, or other heart conditions. Some muscle relaxants such as carisoprodol (Soma) can be habit forming and difficult to come off of.

Anticonvulsants

Anticonvulsants commonly used to treat neuropathic (nerve) pain have been found to be effective in the treatment of certain chronic pain disorders such as fibromyalgia, diabetic neuropathy or postherpetic neuralgia.

Examples: gabapentin (Neurontin), pregabalin (Lyrica). There are a number of other anticonvulsants that have also shown varying efficacy in chronic pain.

Evidence: Recent systematic review on the efficacy of anticonvulsants on orofacial pain found limited to moderate evidence supporting the use of anticonvulsants for treatment of patients with orofacial pain disorders.

Caution: Gabapentin and pregabalin are associated with some adverse effects (dizziness, blurred vision, drowsiness, etc.) but otherwise are generally considered safe. Other anticonvulsants may have more common and significant adverse effects and you should discuss these with your clinician.

Benzodiazepines

Benzodiazepines are prescribed to treat anxiety, nervousness, panic attacks, seizures, muscle spasms, and insomnia. Benzodiazepines may reduce TMJ pain directly as well as indirectly as a result of its anti-anxiety properties.

Examples: Lorazepam (Ativan), alprazolam (Xanax), clonazepam (Klonopin), and diazepam (Valium)

Evidence: Benzodiazepines have been suggested as treatment options for chronic orofacial pain associated with TMJ despite weak evidence for their efficacy in controlled trials.

Caution: The most serious risk is the potential to develop tolerance and physical dependence to benzodiazepines. Additionally, there may be some side effects (drowsiness, confusion, amnesia, etc.), and benzodiazepines interact with some medications and foods, as they affect an important liver enzyme. These medications are also contraindicated for myasthenia gravis, allergies, and acute glaucoma.

Cannabis

Medical cannabis has been proposed to reduce pain and increase the effects of other pain control regimens for several painful conditions.

Evidence: One study investigated the utility of cannabinoids, the active components of cannabis, for temporomandibular joint-related nociception in rats; it found that the cannabinoids increase the effects of other medications in decreasing inflammatory pain of the TMJ. To date, there is little evidence to inform clinicians and patients on the efficacy of cannabis in chronic pain in general and TMJ pain in particular. The current media hype is far out of proportion to the available evidence and more research is needed.

Caution: Medical cannabis may cause increased heart rate, dizziness, impaired concentration and memory, slower reaction times, negative drug-to-drug interactions, increased risk of heart attack and stroke, increased appetite, potential for addiction, cyclic vomiting syndrome, hallucinations or mental illness, and withdrawal symptoms. One of the major issues with cannabis is that the dose and quality if often not controlled.

Glucosamine and Chondroitin

Glucosamine and chondroitin are structural components of cartilage, the tissue that cushions the joints. Both are produced naturally in the body and also available as dietary supplements.

Evidence: Two studies cited by a systematic literature review found that glucosamine supplements were equally effective regarding pain reduction and mouth opening improvement compared to ibuprofen taken 2-3 times per day over 12 weeks. A third study did not find significant differences in pain reduction or maximum mouth opening between a group receiving glucosamine and a group receiving a placebo over 6 weeks of medication administration. There is very low evidence regarding glucosamine supplements therapeutic effects on temporomandibular joint osteoarthritis. The researchers cautioned that the results of the studies were at risk of bias and should be interpreted with caution.

Caution: Studies have found that glucosamine and chondroitin supplements may interact with the anticoagulant (blood-thinning) drug warfarin (Coumadin). Overall, studies have not shown any other serious side effects.

Topical Medication

Capsaicin (topical)

Capsaicin is a chemical agent derived from chili peppers that has been shown to have analgesic properties.

Evidence: A small study showed some TMJ pain relief after a 1-week period following a single topical application of 8 percent capsaicin cream, but further studies with additional patients are needed to confirm this finding.

Caution: Capsaicin may cause burning, itching, dryness, pain, redness, swelling or soreness at the application site. Less common side effects include cough, difficulty breathing, shortness of breath, sore throat, stuffy or runny nose, and tightness in the chest or wheezing.

Intramuscular Medication

Botulinum Toxin

The injection of botulinum toxin Type A (Botox) into the chewing muscles been proposed to decrease muscle spasm and pain by impairing muscle contraction.

Evidence: A scientific review found inconclusive evidence concerning the effectiveness of botulinum toxin for myofascial pain in the neck and head muscles. A study in which rabbits were injected with either Botox or saline solution into the masseter muscle found a dramatic loss of bite force, after 3 weeks, in the rabbits receiving Botox injections.

Caution: There is concern for the long-term effect of the bone and muscle loss in humans given what occurred in animal models.

Prolotherapy

Prolotherapy is an injection of an irritant solution such as dextrose or saline solution to into a ligament or muscle tendon near a painful area with the intent to promote a reparative immune response thus strengthening these structures, supporting the weakened muscles, and eliminating the pain.

Evidence: Limited or no evidence to support their use for this purpose, or the evidence is mixed.

Caution: Possible side effects may include swelling, intense pain and stiffness, headache, allergic reaction, and potential infection at site of injection.