Treatment Options for Upper Back Pain
For acute upper back pain, start with NSAIDs (such as ibuprofen) as first-line medication combined with heat application and continued activity, reserving skeletal muscle relaxants for patients who do not respond within 2-4 days. 1
First-Line Pharmacologic Treatment
- NSAIDs (ibuprofen, naproxen) are the preferred initial medication, providing small to moderate improvements in pain intensity with moderate-quality evidence. 1, 2
- Prescribe NSAIDs at the lowest effective doses for the shortest periods necessary, assessing cardiovascular and gastrointestinal risk factors before initiating therapy. 2
- Most head-to-head trials show no differences between different NSAIDs, so selection can be based on cost, availability, and individual patient factors. 3, 2
Alternative First-Line Option
- Acetaminophen (up to 3000mg/day) is an alternative for patients with contraindications to NSAIDs, particularly elderly patients, though it provides slightly less pain relief. 1, 4
- Acetaminophen has a more favorable safety profile than NSAIDs but shows no significant difference from placebo for pain intensity in some acute low back pain studies. 2
- Monitor for hepatotoxicity when using maximum doses, especially in elderly patients or those with hepatic impairment. 2
Essential Non-Pharmacologic Measures
- Patients must remain active and continue ordinary activities within pain limits—avoid bed rest entirely, as activity restriction prolongs recovery. 1, 4, 2
- Apply superficial heat using heating pads or heated blankets for short-term symptomatic relief in acute upper back pain. 1, 4, 2
- Use a medium-firm mattress rather than a firm mattress for better pain relief. 1, 4
Second-Line Pharmacologic Treatment
- Skeletal muscle relaxants (such as cyclobenzaprine) should be considered if pain persists after 2-4 days of NSAIDs, with moderate-quality evidence showing improved short-term pain relief after 2-7 days compared to placebo. 1, 2
- Cyclobenzaprine is indicated as an adjunct to rest and physical therapy for relief of muscle spasm associated with acute, painful musculoskeletal conditions. 5
- All skeletal muscle relaxants cause central nervous system adverse effects, primarily sedation, which patients must be counseled about. 2
- Cyclobenzaprine should be used only for short periods (up to two or three weeks) because adequate evidence of effectiveness for more prolonged use is not available. 5
- Start with 5 mg doses in elderly patients and those with mild hepatic impairment, titrating slowly upward; avoid use in moderate to severe hepatic impairment. 5
When Initial Treatment Fails
- For patients who do not improve with self-care and medications, consider spinal manipulation administered by appropriately trained providers, which is associated with small to moderate short-term benefits for acute pain. 3, 2
- Supervised exercise therapy is not effective for acute upper back pain but becomes beneficial after 2-6 weeks for subacute pain. 3
Treatments NOT Recommended
- Systemic corticosteroids should not be used, as low-quality evidence shows no difference in pain or function compared with placebo. 3, 1, 2
- Benzodiazepines show similar effectiveness to skeletal muscle relaxants but carry risks for abuse, addiction, and tolerance; if used, only prescribe time-limited courses. 2
- Insufficient evidence exists to recommend antidepressants or antiseizure medications for acute upper back pain. 2
Opioid Considerations (Last Resort Only)
- Opioids should be reserved only for severe, disabling pain not controlled with acetaminophen and NSAIDs, and only after carefully weighing potential benefits and harms. 1, 2
- Substantial risks include aberrant drug-related behaviors, abuse potential, and addiction. 2
Red Flags Requiring Immediate Attention
- Severe or progressive neurologic deficits (weakness, numbness, loss of bowel/bladder control) require immediate medical attention. 4
- Suspicion of serious underlying conditions such as cancer, infection, or spinal fracture requires immediate evaluation. 4
- Diagnostic imaging is not recommended unless there is suspicion of serious underlying pathology or no improvement after 6 weeks. 1
Critical Pitfalls to Avoid
- Do not prescribe bed rest or activity restriction—this provides no benefit and delays recovery. 4, 2
- Do not use extended courses of medications without clear evidence of continued benefits and absence of major adverse events. 3, 2
- Do not pursue routine imaging (X-rays, MRI, CT) for nonspecific upper back pain without red flags, as findings are often nonspecific and do not improve outcomes. 4