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Zanaflex vs. Flexeril for Fibromyalgia

Introduction

Pain from fibromyalgia can be quite bothersome. Often, it can have a severe impact on your quality of life, making even normal tasks difficult. Two muscle relaxants called Zanaflex and Flexiril (cyclobenzaprine) are among the drugs used to treat fibromyalgia. Learn how they compare.

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Basic features

Drug features

Flexeril was one popular brand name for the drug cyclobenzaprine. Although the brand Flexeril is no longer available, many doctors still use its name to refer to cyclobenzaprine.  Cyclobenzaprine likely treats fibromyalgia by increasing the effects of norepinephrine, a substance in your brain and spinal cord that helps reduce pain signals.

Zanaflex is the brand name for the drug tizanidine. It’s believed to work by reducing the release of substance P in your brain and spinal cord. Substance P is a chemical that helps increase pain signals to and from the brain.

Both of these drugs work to treat fibromyalgia pain and decrease muscle spasms.

The table below summarizes other drug features of both tizanidine and cyclobenzaprine.

Brands Zanaflex Flexiril (Amrix)*
What is the generic name? tizanidine cyclobenzaprine
Is a generic version available? yes yes
What does it treat? fibromyalgia pain fibromyalgia pain
What forms does it come in? oral capsule, oral tablet oral tablet, extended-release oral capsule
What strengths does this drug come in? oral tablet: 2 mg, 4 mg; oral capsule: 2 mg, 4 mg, 6 mg oral tablet: 5 mg, 7.5 mg, 10 mg; extended-release oral capsule: 15 mg, 30 mg
How do I store it? at controlled room temperature between 59°F and 86°F (15°C and 30°C) at controlled room temperature between 59°F to 86°F (15°C to 30°C)
Is there a risk of withdrawal with this drug? yes† yes†
Does this drug have potential for misuse? yes†† yes††
 
*Cyclobenzaprine is no longer sold under the brand name Flexeril.
† If you’ve been taking this drug for longer than a few weeks, don’t stop taking it without talking to your doctor. You’ll need to taper off the drug slowly to avoid withdrawal symptoms such as anxiety, sweating, nausea, and trouble sleeping.
†† A high misuse potential means you can get addicted to this drug. Be sure to take it exactly as your doctor tells you to. If you have questions or concerns, talk with your doctor.

Warnings

Alcohol and withdrawal risks

Do not drink alcohol while using either tizanidine or cyclobenzaprine. Drinking alcohol with either drug may cause severe drowsiness and make you much less alert. This effect can make activities such as driving difficult and unsafe.

You also should not stop taking tizanidine or cyclobenzaprine suddenly. Doing so can cause withdrawal symptoms. This is especially likely if you’ve been taking either drug for a long time.

Withdrawal symptoms of tizanidine include:

  • high blood pressure
  • fast heart rate
  • increased muscle tone
  • tremors
  • anxiety

Withdrawal symptoms of cyclobenzaprine include:

  • nausea
  • headache
  • tiredness

If you need to stop taking either drug, your doctor will slowly lower your dosage over time.

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Cost and availability

Cost, availability, and insurance

Tizanidine and cyclobenzaprine are both available as brand-name and generic drugs. Generally, the brand-name drugs are more expensive than the generics. Between the generics, tizanidine is more expensive than cyclobenzaprine. Both drugs are available in most pharmacies.

Health insurance plans usually cover the generic forms of both drugs without prior authorization. In many cases, insurance companies will require a prior authorization for Zanaflex or Amrix.

Side effects

Side effects

Tizanidine and cyclobenzaprine cause similar side effects. The chart below compares examples of side effects of both drugs.

Common side effects Tizanidine Cyclobenzaprine
dry mouth X X
drowsiness X X
dizziness X X
weakness or lack of energy X X
constipation X X
nervousness X X
urinary tract infection X
vomiting X
abnormal liver function test results X
headache X
confusion X
nausea X
indigestion X
unpleasant taste X
speech disorders X
blurry vision X X
needing to urinate more often than normal X
flu-like symptoms X
trouble performing voluntary movements X
 

These drugs also have shared serious side effects, including:

  • heart rhythm changes
  • low blood pressure
  • liver problems
  • severe allergic reactions (may cause a rash, itching, swelling of your throat, or trouble breathing)

In rare cases, liver problems from these drugs may cause hepatitis (inflammation of your liver) and jaundice ( yellowing of your skin and whites of eyes).

Tizadinine can also cause extreme drowsiness and hallucinations (seeing or hearing things that aren’t real) or delusions (false beliefs). Additionally, cyclobenzaprine can cause:

  • serotonin syndrome, with symptoms such as confusion, hallucinations, agitation, sweating, higher body temperature, tremors, seizures, stiff muscles, nausea, vomiting and diarrhea
  • urinary problems, such as not being able to urinate or to fully empty your bladder
  • seizures
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Drug interactions

Drug interactions

Tizanidine and cyclobenzaprine can interact with certain other drugs. For instance, both drugs interact with central nervous system (CNS) stimulants like alcohol, narcotics, and benzodiazepines. Taking either tizanidine or cyclobenzaprine with a CNS stimulant can cause intense drowsiness. Both drugs also interact with certain high blood pressure drugs.

Here are examples of other drugs that may interact with tizanidine and cyclobenzaprine.

Tizanidine Cyclobenzaprine
CNS depressants such as benzodiazepines, opioids, and tricyclic antidepressants CNS depressants such as benzodiazepines, opioids, and tricyclic antidepressants
high blood pressure drugs such as clonidine, guanfacine, and methyldopa high blood pressure drugs such as clonidine, guanfacine, and methyldopa
heart rhythm drugs such as amiodarone, mexiletine, propafenone, and verapamil monoamine oxidase inhibitors (MAOIs) such as phenelzine, tranylcypromine, and isocarboxazid
antibiotics such as levofloxacin, moxifloxacin, and ofloxacin certain depression and anxiety drugs
oral contraceptives (birth control pills) pain drugs such as tramadol or meperidine
ciprofloxacin bupropion
fluvoxamine verapamil
cimetidine
famotidine
zileuton
acyclovir
ticlopidine
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Health concerns

Use with other medical conditions

Both tizanidine and cyclobenzaprine can cause problems if you take them when you have certain other health issues. You should avoid using either of these drugs if you:

  • have liver disease
  • are pregnant or breastfeeding
  • have a slow heart rhythm or heart rhythm problems

You should also discuss the safety of tizanidine if you have kidney disease or low blood pressure. Talk to your doctor about the safety of cyclobenzaprine if you have:

  • hyperthyroidism
  • recent heart attack
  • heart failure
  • seizure disorder
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Takeaway

Talk with your doctor

Tizanidine and cyclobenzaprine are muscle relaxants that help treat muscle pain from fibromyalgia. Objectively, one medication is not clearly more effective than the other. Your doctor will choose the best drug for you based on factors like your health and any other medications you’re taking.

Article resources
  • Clauw, D. J. (2014). Fibromyalgia: A clinical review. Journal of the American Medical Association, 311(15), 1547-1555. Retrieved from
  • Cyclobenzaprine. (2010, November). Retrieved from
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  • Fibromyalgia. (n.d.). Retrieved from
  • Giovannitti, J. A., Thoms, S. A., Crawford, J. J. (2015). Alpha-2 adrenergic receptor antagonists: A review of current clinical applications. Anesthesia Progress, 62(1), 31-38. Retrieved from
  • Tizanidine. (2015, November). Retrieved from
  • Tizanidine hydrochloride – tizanidine hydrochloride capsule, gelatin coated. (2015, April 1). Retrieved from
  • Tizanidine hydrochloride – tizanidine hydrochloride tablet. (2014, October). Retrieved from
  • U.S. Food and Drug Administration. (2014, January 31). Living with fibromyalgia, drugs approved to manage pain. Retrieved from
  • Zanaflex-tizanidine hydrochloride capsule; tizanidine hydrochloride tablet. (2013, November 11). Retrieved from
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