(From the protocol at www.Vitality101.com.)
___ 214.* Ultram (Rx, Tramadol) — 50 mg 1-2 tablets up to 4 times a day as needed for pain. Side effects are less with 4 or fewer tablets a day. May cause nausea/vomiting. Caution: May very rarely cause seizures or raise serotonin too high when combined with antidepressants.
___ 215.* Nerve pain cream or gel (Rx) — Rub a pea size amount onto painful areas 3 times a day as needed (from ITC Pharmacy). You can use this on up to 3-4 "silver dollar" sized areas at a time.
___ 216.* Lidocaine Patches (Lidoderm Rx) — Can be cut into pieces to put over different areas. Leave the patch on for 12-18 hours, then off the rest of the day. It can help localized pain (i.e., it helps pain that is right under the patch). Up to 4 patches can be used at a time each day. It can take 2-3 weeks to see if it works.
___ 217. Daypro (Rx) — 600 mg 2 each morning as needed. Aspirin family medications can cause stomach bleeding. Take with an antacid or food if it upsets your stomach. If gastritis persists, stop the medicine or lower the dose. If you have a black stool (and are not taking iron tablets or Pepto Bismol), this may represent a life threatening stomach bleed (the stool will often have a very foul smell). If this occurs, go to the emergency room immediately.
___ 218. Voltaren (Rx) — _____ mg _____ times a day as needed. Aspirin family medications can cause stomach bleeding. Take with an antacid or food if it upsets your stomach. If gastritis persists, stop the medicine or lower the dose. If you have a black stool (and are not taking iron tablets or Pepto Bismol), this may represent a life threatening stomach bleed (the stool will often have a very foul smell). If this occurs, go to the emergency room immediately.
___ 219A.* Celebrex (Rx, Celecoxib) — 100-200 mg 1-2 times a day for pain. Do not take if you're allergic to sulfa or Aspirin (e.g., hives). Do not use over the 200 mg a day while on Sporanox or Diflucan. An herbal supplement that provides relief for muscle pain (with boswellia and white willow bark; or Curcumin, boswellia, nattokinase, and DLPA) is a natural form and is safer.
___ 220A.* Neurontin (Rx, Gabapentin) — ____mg ____ times a day (to a maximum of 3,600 mg a day). Cut back and increase by 100 mg a day each 4-5 days if it causes any uncomfortable or unusual neurologic symptoms or excessive sedation. Begin with 100-300 mg at night, and slowly increase to 300-900 mg 3 times a day as is comfortable. In some, pain relief is immediate. In others, it can take a minimum of 1,200 mg a day. You can go up to 3,600 mg a day.
___ 220B. Gabitril (Rx) — 2-4 mg twice a day and increase by a maximum 4 milligrams daily, each 3-7 days to a maximum of 24 mg a day. Helps both pain and deep sleep. The main side effects are sedation, dizziness and gastric upset.
___ 220C. Lyrica (Pregabalin Rx) is helpful for pain, increasing deep sleep, and restless legs syndrome. The main side effects are dizziness and drowsiness, which tend to decrease over time. Unfortunately, it also has a side effect of causing weight gain at doses over 300 mg a day. Consider 250-300 mg at bedtime, though 300 mg 2x day is the optimal dose in some studies.
___ 221. Flexeril (Rx, cyclobenzaprine) — 10 mg 1/2-2 at bedtime. Muscle relaxant — can cause dry mouth.
___ 222.* Skelaxin (Rx, metaxolone) — 400 mg 1-2 tablets 4 times a day as needed for pain. This is usually non-sedating.
___ 223. Baclofen (Rx) — 10-20 mg 1-3 times a day (sedating).
Antidepressants can be very helpful in alleviating pain, even you are not depressed! Do not presume that your pain specialist thinks that you have a psychological problem if you're offered an antidepressant. Tricyclic antidepressants (e.g., Elavil/amitriptyline, doxepin, etc.) can be dramatically beneficial (even at very low doses) for neuropathic pain. They also improve the sleep problems caused by the pain. SSRI antidepressants such as Prozac, Effexor, and Celexa can also be highly effective for pain. These medications raise serotonin, which lower levels of a major pain messenger (substance P).
___ 227A. Elavil (Rx, amitriptyline) — 10 mg 1/2-5 tablets at bedtime. May cause weight gain or dry mouth. Good for nerve pain and vulvadynia.
___ 227B.* Desipramine (norpramin) — use 25-150 mg at bedtime or ____nortriptyline (Pamelor — 10-25 mg at bedtime) cause less sedation and other side effects than Elavil, and may be as effective. If sedation is still a problem, consider switching to doxepin 10-40 milligrams at bedtime.
___ 227C.* Doxepin (Rx, Sinequan) — 5-10 mg, 1-3 capsules at bedtime or Doxepin liquid 10 mg/cc. If a lower dose is needed you can start with 1-3 drops at night. A powerful antihistamine. Some people get the greatest benefit with the least next-day sedation with a dose of less than 5 mg a night.
___ 228. Savella (Minalcipran) — 100 mg a day. Higher doses caused no increase in pain relief but a marked increase in side effects (nausea). The medication will likely be released in the latter half of 2009 in the U.S. and is currently available in Europe.
___ 228A. Effexor (Rx) — (venlafaxine) 37 ½ mg _____ tablets _____ times a day.
___ 228B. Prozac (Rx) — (fluoxetine) 20 mg _____ capsule(s) each morning. Begin with 10 mg a day the first week if the full dose makes you hyper.
___ 228C. Celexa (Rx) — 20 mg ____ tablet(s) a day
___ 229. Cymbalta (duloxetine) — 60 mg 2x a day. A norepinephrine and serotonin reuptake inhibitor. It has fewer side effects and does not cause weight gain. It has been shown to be very helpful in addressing FMS pain.
Alpha 2 Adrenergic Agonists:
___ 230A.* Zanaflex (Rx, tizanidine) — 4 mg. Take with food 1/2-2 tablets 1-2 times a day as needed for spasm and/or pain (sedating). Begin with 2-4 mg at night. If side effects occur raise dose more slowly, increasing by 2 mg at bedtime each 4 nights until you are on 8-12 mg at bedtime. Stop if it causes nightmares.
___ 230B. Catapres TTS 1 Patch (Rx) — Wear 1-3 at a time and change patch weekly. Related to Zanaflex but cheaper and lowers blood pressure more. Helps pain and raises growth hormone.
NMDA Receptor Antagonists:
___ 231A.* Klonopin (Rx, clonazepam) — 1/2 mg, begin slowly and work your way up as sedation allows. Begin with 1/2 tablet at bedtime increasing to 1-2 mg 3x day as needed. Can be very effective for sleep, pain and anxiety (it is in the valium family). Klonopin may be addictive. Taking one quarter to one half tablets in the morning (not more) can actually decrease brain fog in some pain patients.
___ 231B.* Namenda (memantine) — 5-10 mg 1-2x day (may need to start at 5 mg a day and increase dose by 5 mg daily each week to avoid side efects). Though I do not find it helpful for Alzheimer's (which is what it is marketed for), the pleasant surprise is that it often helps pains' resistant to other therapies. It is especially helpful for nerve pain and allodynia pain (where normal touch hurts).
___ 232. Dextromethorphan (Rx, DM) — 25 mg 2 times a day if on narcotics (e.g., codeine/Vicodin) makes the narcotic more effective and less likely to lose effectiveness. From Cape Drugs 800-248-5978.
___ 233. Amantadine(Rx) — 100 mg 1-3 tablets each morning may help nerve pain and also is an antiviral. The most common side effects include visual blurring, dizziness, and nausea.
___ 234. Keppra(Rx) is another new anti-seizure medication that we are just starting to explore which has been effective when other therapies have not helped. The dose is 250-1,500 mg twice daily. Can help "burning pain."
___ 235. Topamax (Rx-topiramate). Begin with 25-50 mg daily, and increase it by 25-50 mg a week until you get the desired effect. This medication is usually given twice a day at a total daily dose of 50-100 mg/day for migraines and 200-300 mg a day for nerve pain, although lower doses can be effective. This is a medication that I have seen work wonderfully in patients who failed numerous other therapies and sometimes starts working within a few days. If you get side effects, decrease the dose and perhaps later increase it more slowly until you get the desired effect. The most common side effects are diarrhea, loss of appetite, sedation, and nausea. The nausea will often go away after one has been on the Topamax for three months. It also has the benefit of causing weight loss as well as pain relief. Besides sedation, its most worrisome albeit unusual side effect is that it can make your body very acidic — to the point where it is dangerous. Because of this, it is reasonable to check a blood bicarbonate level every so often (especially if you start developing symptoms such as fatigue) to make sure that it is over 17.
___ 236. Benadryl — 25+ mg 3-4 times daily can often markedly decrease pain (worth trying).
___ 237. Lamictal (Rx, Lamotrigine) — 25 mg 1 at bedtime for 1 week. Can then increase to 1 three times a day for 1 week. You can go as high as 100 mg 4 times a day. Although rare, it can cause a rash that, if you stay on the medication, can be fatal. Although most rashes would not be this, to be on the safe side — STOP LAMICTAL AT FIRST SIGN OF ANY RASH!
___ 238. Trileptal (Rx) — 150 mg twice a day. Can go as high as 600 mg 2 times a day.
___ 239. Zonegran (Rx) — 100 mg. An anti-seizure medication. Begin with 100 mg/day for two weeks and then increase to two tablets a day. The maximum dose is 400 mg daily, although most of the benefit occurs at the first 200 mg. Because there have been rare occurrences of a life threatening rash (most rashes caused by the medication are not however), stop the medication immediately if you get a rash.
___ 240. Permex (Rx, Pramipexole) — 1/4 mg. Begin with 1 a night and increase by 1 tablet weekly as needed to a maximum of 6 mg. In one study it resulted in a 50% reduction in pain after 2 months at an average dose of 1.5 mg at bedtime. If stomach pain occurs, Nexium or similar medications are used during the first month. If restless leg syndrome worsens, Klonopin is also added at bedtime. Both of these side effects generally go away as the dose is increased.
Jacob Teitelbaum, M.D. is one of the world's leading integrative medical authorities on fibromyalgia and chronic fatigue. He is the lead author of eight research studies on their effective treatments, and has published numerous health & wellness books, including the bestseller on fibromyalgia From Fatigued to Fantastic! and The Fatigue and Fibromyalgia Solution. Dr. Teitelbaum is one of the most frequently quoted fibromyalgia experts in the world and appears often as a guest on news and talk shows nationwide including Good Morning America, The Dr. Oz Show, Oprah & Friends, CNN, and Fox News Health.