The Problem
A 59-year-old female with a history of hypertension and hypercholesterolemia presents with a several-month history of leg cramps. The cramping is worse at night and frequently wakes her from sleep. She massages her legs or uses heat during particularly bad spells, which seems to alleviate her symptoms somewhat. She is currently on hydrochlorothiazide/triamterene and simvastatin and has been for several years. She denies irresistible urges to move her legs during rest or recumbency. She has been using an over-the-counter product containing quinine that she purchased online. It seems to help and she requests a prescription from you. You inform the patient that legs cramps are not a Food and Drug Administration–approved indication for quinine (malaria treatment is the only FDA-approved indication). The FDA has halted the manufacture of unapproved prescription quinine products, and the FDA has warned consumers about its use. She wonders what else she can try. Her examination is normal apart from a slightly elevated blood pressure of 150/92 mm Hg. Lab results show her calcium, magnesium, creatinine, and liver function to be normal. You try discontinuing her statin for 2 weeks, but her symptoms do not relent. You admit to her that she is already doing what you would have recommended (massage and heat) and that you need to do additional research.
The Question
What treatments are effective for muscle cramps?
The Search
You open PubMed, and enter the terms “muscle cramps” and limit to “review.”
Our Critique
The search was limited to two databases, which makes it possible that some articles were missed. However, the databases are arguably the largest and most comprehensive. Article selection and grading of evidence seem appropriate. Overall, the review provides useful information regarding treatment options when patients request assistance with their muscle cramps.
Clinical Decision
You discuss the options with your patient. They include vitamin B complex and calcium channel blockers. You agree to try diltiazem for her leg cramps and to improve her blood pressure control. She contacts you two weeks later with a report of a 50% improvement in the number and intensity of her leg cramps.
Dr. Ebbert and Dr. Tangalos are with the Mayo Clinic in Rochester, Minn. They report having no conflicts of interest. To respond to this column or suggest topics for consideration, write to Dr. Ebbert and Dr. Tangalos at our editorial offices or e-mail them at imnews@elsevier.com.
The Evidence
Assessment: symptomatic treatment for muscle cramps (an evidence-based review): report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology (Neurology 2010;74:691-6).
P Study Design: Systematic review
P Search Strategy: A comprehensive search of MEDLINE and EMBASE from 1950 to 2008 was conducted using keywords and four languages (English, French, German, and Spanish). Additional articles were identified by cross-referencing bibliographies, meta-analyses, review articles, and case reports identified in the initial search. “Muscle cramps” were defined as a sustained, generally painful, involuntary contraction of the muscle or muscle group.
P Article inclusion: Abstracts and titles from identified articles were reviewed and the study was included if there was a prospective clinical trial with effect on muscle cramps as a primary or secondary outcome. Articles were excluded if they were reviews, meta-analyses, case reports, related to phenomena not consistent with muscle cramps, pregnancy-induced or cirrhosis/hemodialysis-related cramps, or cramps from physiologic stress, heat, or dehydration.
P Evidence Grading: Data on study design was extracted and each article classified according to the American Academy of Neurology therapeutic classification of evidence scheme (Class I-IV) and recommendations were based on the level of evidence (A = established to be effective, ineffective, or harmful; B = probably effective, ineffective, or harmful; C = possibly effective, ineffective, or harmful; U = Data inadequate or conflicting).
P Results: 563 articles were identified and 24 articles were chosen for inclusion in the final review.
P Findings/Recommendations: Few studies have evaluated nonpharmacologic treatment for muscle cramps and data are insufficient to draw conclusions about calf stretching (Level U). Vitamin B complex and diltiazem are possibly effective for the treatment of muscle cramps (Level C). Data for the efficacy of diltiazem are based upon a blinded, crossover study of 13 patients evaluating the effects of 30 mg of diltiazem hydrochloride on the number and intensity of cramps in patients experiencing 2 or more cramps per week. A reduction in the number of cramps over time in patients treated with diltiazem, compared with placebo, was observed (–5.84 to –0.16 cramps/2-week treatment phase, P = .04) with no effect on the intensity of cramps. A blinded, placebo-controlled study of vitamin B complex (30 mg/day) randomizing 28 patients observed a remission of muscle cramps in 86% of treated patients receiving active medication who were not known to be vitamin deficient. Although agents such as baclofen and carbamazepine often are employed in clinical practice for the treatment of muscle cramps, no clinical trial data exists evaluating their efficacy. Data regarding the use of magnesium preparations and gabapentin demonstrate that these agents are probably not effective for muscle cramps treatment.