Ointments for headaches and neck pain

There is a long history of applying various ointments for the treatment of headaches. Widely available Tiger Balm, Head-On and other topical products can provide relief of milder headaches. There are no scientific studies proving that these treatments work beyond the placebo effect, although we do have some evidence established by Hartmut Gobel and his colleagues in Germany suggesting that the smell of peppermint can provide some pain relief. So it is possible, that the smell of herbs in Tiger Balm and possibly the cooling effect of these ointments combined with placebo effect is what accounts for the popularity of these products.
I have been using a prescription ointment for some of my patients with headaches and neck pain. This ointment has to be prepared by a compounding pharmacy and typically is not available from big chains, such as CVS or Walmart, although Walgreens does offer compounding services at some of its pharmacies. We do not have any information about the best combination of ingredients to use for the relief of headaches and pain. However, some studies indicate that topical skin application of some products does provide relief. Ketamine, which blocks the so called NMDA pain receptor can relieve pain of complex regional pain syndrome, a very serious and painful condition. Application of clonidine, a blood pressure medication has been shown to relieve pain of diabetic neuropathy – painful nerve damage due to diabetes. We also know that lidocaine is very effective when applied to the skin and it is the active ingredient in a prescription pain patch, Lidoderm. Anti-inflammatory drugs, such as aspirin or similar salicilate drugs (Aspercreme), diclofenac (Flector patch), piroxicam and other also help pain when applied to the skin. There are no studies of topical application of muscle relaxants, such as baclofen and tizanidine or an epilepsy drug gabapentin, but these drugs are often also included in compounded creams.
My usual prescription is to combine ketamine with lidocaine, piroxicam and baclofen. Unfortunately, we do not know what is the most effective combination and it would be very difficult to compare so many available ingredients in a scientific study. However, these creams are safer than oral drugs and for some patients can be as effective. Another drawback of the compounded products is that insurance often will not pay for it.