What medications are recommended for a sciatica flare?

Medication Management for Sciatica Flare

Start with continuous NSAIDs (not on-demand dosing) as first-line therapy, add gabapentin if response is inadequate after 1-2 weeks, and consider a short course of muscle relaxants for acute severe spasms—avoid systemic corticosteroids entirely as they are ineffective. 1, 2

First-Line: NSAIDs (Continuous Dosing)

• NSAIDs should be prescribed on a continuous schedule rather than as-needed dosing for inflammatory radicular pain 2
• Choose one of the following regimens:
  • Naproxen 500 mg twice daily (preferred for cardiovascular safety profile) 2
  • Ibuprofen 400-800 mg three times daily 2
  • Meloxicam 7.5-15 mg once daily (COX-2 selective, fewer GI side effects) 2, 3
• Evidence shows NSAIDs provide global improvement (RR 1.14,95% CI 1.03-1.27) though pain reduction may be modest 4
• Monitor for GI bleeding, cardiovascular events, and renal dysfunction, especially with prolonged use 2, 3

Second-Line: Add Gabapentin for Neuropathic Component

Sciatica is a mixed pain syndrome with both nociceptive and neuropathic components—NSAIDs alone only address the inflammatory component 5

• Gabapentin is particularly effective for the radicular/neuropathic pain component of sciatica 1, 2, 6
• Add gabapentin if inadequate response to NSAIDs after 1-2 weeks 1
• Dosing schedule:
  • Start 300 mg once daily at bedtime 6
  • Titrate gradually to 300-600 mg three times daily as tolerated 6
  • Maximum effective dose typically 900 mg three times daily 6
• Monitor for sedation, dizziness, and peripheral edema; adjust dose in renal impairment 2

Third-Line: Tricyclic Antidepressants

• Amitriptyline provides moderate pain relief for chronic radicular pain when NSAIDs and gabapentin are insufficient 1, 2
• Dosing:
  • Start 10-25 mg at bedtime 2
  • Titrate by 10-25 mg weekly as tolerated 2
  • Target dose 50-75 mg at bedtime 2
• Particularly useful if depression coexists with chronic pain 1

Adjunctive Therapy for Acute Severe Flares

Muscle relaxants for short-term use (2-3 weeks maximum) during acute exacerbations with severe muscle spasm: 1, 2

• Cyclobenzaprine 5-10 mg three times daily (most evidence for acute back pain) 1, 2
• Tizanidine 2-4 mg three times daily, can increase to 8 mg three times daily 2
• Use with caution due to sedation and potential hepatotoxicity with tizanidine 1
• Combining muscle relaxants with NSAIDs increases CNS adverse events 1

Medications to AVOID

Systemic corticosteroids are NOT recommended—three high-quality trials consistently show no benefit over placebo for sciatica: 1, 2

• Oral or injectable steroids are ineffective for radicular pain 1, 2
• This represents a common pitfall in practice—many clinicians still prescribe steroid tapers despite clear evidence of inefficacy 2

Opioids should be avoided except as very short-term rescue therapy: 1, 2

• Limited evidence for modest short-term effects 1, 2
• Significant risks: constipation, sedation, nausea, abuse potential 1, 2
• If absolutely necessary for severe acute pain, tramadol 50-100 mg every 4-6 hours (max 400 mg/day) is preferred over stronger opioids 2

Benzodiazepines are ineffective for radiculopathy and carry abuse/addiction risks 1, 2

Practical Treatment Algorithm

1. Day 1-14: Start continuous NSAID (naproxen 500 mg BID preferred) 2
2. If inadequate response at 1-2 weeks: Add gabapentin, starting 300 mg at bedtime, titrate to 300-600 mg TID 1, 2, 6
3. If severe muscle spasm present: Add cyclobenzaprine 5-10 mg TID for maximum 2-3 weeks 2
4. If still inadequate after 4-6 weeks: Add amitriptyline 10-25 mg at bedtime, titrate to 50-75 mg 2
5. Reassess efficacy and side effects at each step 1

This stepwise approach targets both the inflammatory and neuropathic components of sciatica while avoiding ineffective therapies like systemic corticosteroids 1, 2, 5