Disclaimer: This is for informational purposes only. This does not replace the instructions you received from Dr. Anderson or any other practitioner,
constitute medical treatment, establishment of a patient-physician relationship, constitute any form of recommendation, prescription or medical
advice, or imply that the medication is appropriate or FDA approved for any condition. This information may be outdated and is not a complete
listing of instructions, doses, uses, or side effects. If this was prescribed to you, you must review this information with your pharmacist and
prescriber before starting the medication. Any medication may interfere with the ability to drive, concentrate, or operate machinery; patients must
be responsible for their own behavior and should not engage in any dangerous activity if there is any question of impairment. All medications have
side effects and drug interactions, some serious, some fatal. Let all of your practitioners and pharmacist know about every substance used. Alcohol,
herbals, or illegal drugs are not considered safe with these medications. Assume no medication is safe during pregnancy or while breast feeding. The
medication may interfere with birth control. Almost any medication can cause sleepiness, insomnia, dizziness, confusion, hallucinations, anxiety,
panic, constipation or diarrhea, headache, chest pain and nausea or vomiting, among others. These could cause physical injury, such as dizziness
causing one to fall down stairs. Many reduce blood pressure, which could cause fainting, dizziness, stroke, or other problems. Most medications
should NOT be stopped suddenly because of the risk of withdrawal. This is a supplement to the standardized drug information sheets.
Drug: TIZANIDINE
Wayne E. Anderson, D.O.
A Medical Corporation
Chronic Intractable Pain Disorders
Headache & Facial Pain Disorders
Neurotoxin Therapy
FDA-approved uses: Tizanidine is a short-acting drug for the
management of spasticity. Because of the short duration of effect,
treatment with tizanidine should be reserved for those daily activities
and times when relief of spasticity is most important.
Common off-label uses: Neuropathic pain conditions of many
causes, musculoskeletal pain, chronic pain. Studies have shown
tizanidine helpful for muscle pain, neuropathic pain, and some types
of headache.
Alternatives: Non-medication modalities, pain interventions and
other medications that may work in a similar manner.
Board Certified Neurology
American Board of Psychiatry & Neurology
Board Certified Pain Medicine
American Board of Psychiatry & Neurology
in association with the
American Board of Anesthesiology
Subspecialty Certified Headache Medicine
United Council for Neurological
Subspecialties
Qualified Medical Evaluator
Member of the
California Pacific Neuroscience Institute
45 Castro Street Suite 225
San Francisco CA 94114
415.558.8584 tel
415.513.4521 fax
www.wayneanderson.net
How it works: It works through nerve alpha-2-receptor activity as an
agonist at those receptors.
Side effects: Please see the standardized drug information sheet for
detailed information about risks, side effects, interactions, and other
important information. Tizanidine should be used carefully in cases
of liver or kidney disease, low blood pressure, or heart conduction
problems (QT interval problems). It should not be used with Luvox
or with the antibiotic Cipro (ciprofloxacin). Other drugs that can
interact with Zanaflex include acyclovir, cimetidine, famotidine,
ticlopidine, zileuton, birth control medications, multiple antibiotics
(everything ending in –floxacin), some blood pressure medications
and some heart rhythm medications. There may be additional risk if
used with methadone. In addition to the standard side effects listed
in the disclaimer, common side effects or Zanaflex include dry
mouth, sleepiness, dizziness, asthenia, infection, constipation,
urinary frequency, flu-like feeling, low blood pressure, more spasms,
sore throat and runny nose. More serious side effects include liver
damage, severe slowing of the heart beat and hallucinations.
Tizanidine occasionally causes liver injury. Because of the many drug
interactions, it is very important that patients provide an accurate
listing of all of their current medications to all of their providers and
also to the pharmacist.
Common doses: The maximum dose of tizanidine is 36mg per day. It
is not likely that a patient will reach the maximum dose; most patients
do well at lower doses. Common doses include 2mg three times daily.
Patients should use the lowest effective dose. There is no need to increase to the next higher dose if the
current dose is helpful. Also, patients should not increase to the next higher dose if the present dose is
not tolerated.
Week
Morning dose
Afternoon dose
Nighttime dose
1
none
none
2 mg
2
2 mg
none
2 mg
3 and on
2 mg
2 mg
2 mg
Time to effect: This medication tends to work as a muscle relaxant shortly after taking it. However, the
neuropathic pain improvement may occur after several weeks.
Financial: Dr. Anderson has never received payment in exchange for prescribing a medication. Dr.
Anderson has not received any payments from the pharmaceutical companies that manufacture
tizanidine or Zanaflex.
Insurance coverage: Many medications, especially in painful conditions, are off-label as discussed
above. Insurance companies do not need to cover medications used off label but typically do provide
coverage for most medications that have good scientific evidence. There is no guarantee that any
medication will be covered. Since this medication is generic, most insurance plans do provide coverage.
However, some insurance plans (including workers compensation plans) limit muscle agents to 14 days.
Clinical and Scientific evidence: Some scientific evidence supportive of the use of the medication is
listed in this section. Of course, scientific information changes rapidly and the information listed may
become outdated or incorrect overnight. Tizanidine has literature supportive of use in neuropathic pain
conditions. It is an alpha-2 adrenergic agonist. Tizanidine has been shown efficacious in reducing
neuropathic pain (1,2) and has been shown to be antihyperalgesic (3). Tizanidine has evidence supportive
of benefit in chronic migraine treatment (4).
References:
1.
2.
3.
4.
Smith H, Elliott J. Curr Opin Anaesthesiol. 2001 Oct;14(5):513-8. Alpha(2) receptors and agonists in pain management.
Semenchuk MR, Sherman S. J Pain. 2000 Winter;1(4):285-92. Effectiveness of tizanidine in neuropathic pain: an open-label study.
Kawamata T, Omote K, Yamamoto H, Toriyabe M, Wada K, Namiki A. Anesthesiology. 2003 Jun;98(6):1480-3. Antihyperalgesic and
side effects of intrathecal clonidine and tizanidine in a rat model of neuropathic pain.
Mathew NT. Neurology. 2009 Feb 3;72(5 Suppl):S14-20. Dynamic optimization of chronic migraine treatment: current and future
options.