From the Guidelines
I would first assess the patient's vital signs and conduct a focused physical examination to determine the severity and potential causes of their back pain and nausea. For immediate relief, I would recommend acetaminophen 650-1000mg orally every 6 hours or ibuprofen 400-600mg orally every 6-8 hours with food for back pain, unless contraindicated, as suggested by the American College of Physicians and the American Pain Society 1. For nausea, ondansetron 4-8mg orally every 8 hours as needed or promethazine 12.5-25mg orally every 6 hours as needed could be prescribed. The patient should be encouraged to maintain proper hydration and rest in a comfortable position. Application of heat or cold packs to the affected area of the back for 15-20 minutes several times daily may provide additional relief. If symptoms are severe, persistent, or accompanied by red flags such as fever, unexplained weight loss, bowel/bladder dysfunction, or radiating pain, immediate medical evaluation is necessary as these could indicate serious conditions like kidney stones, pancreatitis, or spinal pathology, as highlighted in the British Pain Society's pathway for care 1. The combination of back pain and nausea warrants careful evaluation as it may represent referred pain from abdominal organs or medication side effects. Some key considerations in managing back pain include:
- Providing patients with evidence-based information on low back pain with regard to their expected course, advising patients to remain active, and providing information about effective self-care options 1
- Considering the addition of nonpharmacologic therapy with proven benefits, such as spinal manipulation for acute low back pain or intensive interdisciplinary rehabilitation for chronic or subacute low back pain 1
- Being aware of the potential risks and benefits of various treatments, including the use of benzodiazepines, gabapentin, and other medications, as well as the importance of individualized care and patient preferences 1
From the Research
Assessment and Treatment of Back Pain and Nausea
- The patient's complaint of back pain and nausea requires a thorough assessment to determine the underlying cause of the symptoms.
- According to 2, the choice of medication for low back pain should be evidence-based and tailored to the individual patient, with acetaminophen, mild opioids, and NSAIDs being first-line drugs.
- The patient's medical history should be taken into account to reduce the risk of adverse side effects, and a test dose may be considered 2.
- A biopsychosocial approach to back pain provides the best clinical framework, and a detailed history and physical examination with a thorough workup are required to exclude emergent or nonoperative etiologies of back pain 3.
Treatment Options
- Conventional therapies, including lifestyle modifications, nonsteroidal anti-inflammatory drugs, physical therapy, and cognitive behavioral therapy, may be used to treat back pain 3.
- Muscle relaxants, such as cyclobenzaprine hydrochloride, carisoprodol, and metaxalone, may be considered for acute low back pain, but their potential for abuse and adverse side effects should be taken into account 4.
- Over-the-counter analgesics, such as NSAIDs and acetaminophen, may be effective for chronic low back pain, and antidepressants, muscle relaxants, and opioids may also be considered 5.
- Nonpharmacologic treatments, such as physical therapy, chiropractic care, massage therapy, and acupuncture, may be recommended for chronic low back pain, but their cost may be a barrier 6.
Next Steps
- A thorough physical examination and medical history should be taken to determine the underlying cause of the patient's back pain and nausea.
- The patient's symptoms and medical history should be used to guide the choice of treatment, with consideration of the potential benefits and risks of different treatment options 2, 3.
- The patient should be monitored for adverse side effects and the effectiveness of the treatment, with adjustments made as necessary 2, 4.