What are the medications and their doses used to treat sciatica?

Medications for Sciatica: Evidence-Based Treatment Approach

First-Line Pharmacological Treatment

NSAIDs should be the initial medication for sciatica, though evidence shows only modest benefit for global improvement with no significant pain reduction compared to placebo. 1, 2

NSAID Dosing

• Meloxicam: 7.5-15 mg once daily (standard COX-2 selective NSAID dosing) 3
• Naproxen: 500 mg twice daily 4
• Ibuprofen: 400-800 mg three times daily 4

The American College of Physicians recommends continuous NSAID treatment over on-demand dosing for inflammatory back conditions including sciatica, though the evidence quality is low. 3 NSAIDs showed a risk ratio of 1.14 (95% CI 1.03-1.27) for global improvement versus placebo, but no significant pain reduction (MD -4.56,95% CI -11.11 to 1.99). 2

Second-Line: Add Neuropathic Pain Agents

For patients with inadequate response to NSAIDs alone, add gabapentin or pregabalin to target the neuropathic component of sciatica. 1, 5

Gabapentin Dosing

• Starting dose: 300 mg once daily at bedtime 5
• Titration: Increase by 300 mg every 1-3 days as tolerated 5
• Target dose: 900-1800 mg/day divided three times daily 5
• Maximum dose: 3600 mg/day divided three times daily 5

Gabapentin is particularly effective for radicular pain/sciatica with small to moderate short-term benefits for radiculopathy. 1 Case reports demonstrate substantial pain improvement even after first dose, with complete resolution at 600 mg three times daily post-surgery. 5

Pregabalin Dosing (Alternative to Gabapentin)

• Starting dose: 75 mg twice daily (150 mg/day) 6
• Titration: Increase to 150 mg twice daily (300 mg/day) within 1 week 6
• Maximum dose: 300 mg twice daily (600 mg/day) for patients tolerating lower doses without sufficient relief 6
• Renal adjustment required: Dose based on creatinine clearance 6

Third-Line: Tricyclic Antidepressants

If gabapentin/pregabalin are ineffective or not tolerated, add amitriptyline for chronic sciatica. 1, 7

Amitriptyline Dosing

• Starting dose: 10-25 mg at bedtime 1
• Titration: Increase by 10-25 mg weekly as tolerated 1
• Target dose: 50-75 mg at bedtime 1

Tricyclic antidepressants provide moderate pain relief for chronic low back pain with good evidence supporting efficacy. 1 Monitor for anticholinergic side effects including dry mouth, constipation, urinary retention, and sedation. 7

Adjunctive Therapy for Acute Exacerbations

Muscle Relaxants (Short-Term Use Only)

• Cyclobenzaprine: 5-10 mg three times daily for maximum 2-3 weeks 4, 1
• Tizanidine: 2-4 mg three times daily, can increase to 8 mg three times daily 4

Skeletal muscle relaxants show moderate short-term benefits for acute low back pain but should be used with caution due to sedation and CNS adverse events. 4, 1 Combining tizanidine with NSAIDs provides enhanced pain relief but increases risk of CNS side effects (RR for adverse events when combined). 4

Tramadol (Use Sparingly)

• Dose: 50-100 mg every 4-6 hours as needed 4
• Maximum: 400 mg/day 4

Tramadol was moderately more effective than placebo for chronic low back pain after 4 weeks in one higher-quality trial, but evidence is limited. 4

Medications to AVOID

Systemic corticosteroids are NOT recommended for sciatica—three higher-quality trials consistently found no clinically significant benefit compared to placebo. 4, 1

• Methylprednisolone (160 mg IM or 500 mg IV): No difference in pain relief through 1 month versus placebo 4
• Oral steroid tapers: No benefit for acute sciatica 4

Opioids should be avoided—limited evidence for short-term modest effects with significant risks including constipation, sedation, nausea, and potential for abuse/addiction. 4, 1 The 2022 CDC guideline emphasizes nonopioid treatments as default for pain. 4

Benzodiazepines are ineffective for radiculopathy based on low-quality evidence and carry risks of abuse, addiction, and tolerance. 1

Practical Treatment Algorithm

1. Start with NSAID (meloxicam 15 mg daily or naproxen 500 mg twice daily) 1, 3
2. Add gabapentin within 1-2 weeks if inadequate response: start 300 mg at bedtime, titrate to 900-1800 mg/day divided three times daily 1, 5
3. Consider short-term muscle relaxant (cyclobenzaprine 5-10 mg three times daily) for acute exacerbations only 1
4. Add amitriptyline 25-75 mg at bedtime if gabapentin insufficient after 2-4 weeks 1
5. Reassess efficacy and side effects regularly—most sciatica improves within 2-4 weeks with or without treatment 8

Critical Monitoring Parameters

• NSAIDs: Monitor for gastrointestinal bleeding, cardiovascular events, and renal dysfunction, especially with long-term use 3
• Gabapentin/Pregabalin: Monitor for sedation, dizziness, peripheral edema; adjust dosing in renal impairment 1, 6
• Muscle relaxants: Monitor for hepatotoxicity (tizanidine, chlorzoxazone), sedation, and tolerance 1
• Amitriptyline: Monitor for anticholinergic effects, orthostatic hypotension, and cardiac conduction abnormalities 7