What is the initial treatment for a pinched nerve?

Initial Treatment for a Pinched Nerve (Peripheral Nerve Compression)

Start with first-line neuropathic pain medications—gabapentinoids (gabapentin or pregabalin) or duloxetine—combined with conservative physical measures, as these provide the strongest evidence for symptom relief while the nerve recovers. 1, 2

Immediate Conservative Measures

• Avoid bed rest entirely—activity modification without complete immobilization prevents deconditioning and may accelerate recovery 3
• Apply ice or heat to the affected area for symptomatic relief, though evidence for thermal modalities is limited 4
• Use elastic bandaging over the affected area to provide constant mechanical stimulation that may modulate pain transmission 1
• Begin gentle range-of-motion exercises within pain tolerance to prevent stiffness and maintain function 1

First-Line Pharmacological Treatment

The American Academy of Neurology and American Geriatrics Society recommend starting with one of these options 1, 2:

Gabapentinoids (Preferred Initial Choice)

• Gabapentin: Start 100-300 mg at bedtime, gradually increase to 900-3600 mg/day in 2-3 divided doses 1, 5
• Pregabalin: Start 25-50 mg/day in older adults or 75 mg/day in younger patients, increase to 150-600 mg/day in divided doses 1, 6
• These bind to voltage-gated calcium channels and have the most favorable side effect profile 1
• Allow at least 2-4 weeks at therapeutic dose before assessing efficacy 1

Alternative First-Line: SNRIs

• Duloxetine: Start 30 mg once daily for one week, then increase to 60 mg once daily (can go up to 120 mg/day if needed) 1, 2
• Fewer anticholinergic effects than tricyclic antidepressants and no ECG monitoring required 1
• Particularly useful if concurrent depression or anxiety is present 2, 6

Tricyclic Antidepressants (Alternative)

• Nortriptyline or desipramine (secondary amines preferred): Start 10 mg/day in older adults, titrate slowly to maximum 75 mg/day 1, 2
• Obtain screening ECG in patients over 40 years before starting, and use cautiously in cardiac disease 1, 2
• More anticholinergic side effects (dry mouth, constipation, urinary retention, orthostatic hypotension) limit tolerability 1, 2

Topical Treatments for Localized Pain

If the pinched nerve causes localized peripheral pain with allodynia 1, 2:

• 5% lidocaine patches: Apply to painful area for up to 12 hours daily—minimal systemic absorption makes this ideal for older adults 1, 2, 6
• High-concentration capsaicin (8% patch): Single 30-minute application can provide relief for at least 12 weeks, though initial burning sensation occurs 1, 2
• 1% menthol cream: Apply twice daily to affected area and corresponding spinal dermatomal region 1

Physical and Occupational Therapy

• Initiate physical therapy within 2-4 weeks if symptoms persist despite medication 1, 7
• Therapy should include nerve gliding exercises, postural training, and functional restoration 1, 7
• Physical interventions can provide relief over 2-18 months and are important adjuncts to pharmacological treatment 1, 7

Treatment Algorithm

1. Week 1-2: Start gabapentin (300 mg at night, increase every 3 days) OR pregabalin (75 mg/day) OR duloxetine (30 mg daily for 1 week, then 60 mg) 1
2. Week 2-4: Titrate to therapeutic dose and add topical lidocaine if pain is localized 1, 2
3. Week 4-6: If partial response, add medication from different class (e.g., add duloxetine to gabapentin) 1, 2
4. Week 6-8: If inadequate response to first-line agents, consider switching to tricyclic antidepressant OR adding tramadol 50 mg 1-2 times daily (maximum 400 mg/day) 1, 2
5. Beyond 8 weeks: If refractory to medications, refer to pain specialist for consideration of nerve blocks, spinal cord stimulation, or other interventional procedures 4, 1

Special Populations

Older Adults (≥65 years)

• Start all medications at lower doses and titrate more slowly 1, 2
• Prioritize topical agents first (lidocaine patches) due to minimal systemic effects 1, 2
• Avoid tricyclic antidepressants if possible due to fall risk and anticholinergic burden 1, 2

Renal Impairment

• Reduce gabapentin and pregabalin doses according to creatinine clearance 1, 2
• Consider topical lidocaine as first choice to avoid systemic medication 2

Cardiac Disease

• Avoid or use tricyclic antidepressants with extreme caution, limiting doses to <100 mg/day 1, 2
• Duloxetine does not cause significant ECG changes and is preferred 1

Critical Pitfalls to Avoid

• Do not use NSAIDs or acetaminophen as monotherapy—neuropathic pain is resistant to these agents 7, 8
• Avoid opioids as first-line therapy due to limited efficacy for neuropathic pain, risk of dependence, and potential for pronociception 1, 7
• Do not discontinue medications prematurely—allow minimum 2-4 weeks at therapeutic dose before declaring treatment failure 1
• Do not overlook "red flags" requiring urgent evaluation: progressive motor weakness, bowel/bladder dysfunction, or signs of cauda equina syndrome warrant immediate imaging and specialist referral 3
• Avoid inadequate dosing—many treatment failures result from using subtherapeutic doses 6

When to Escalate Care

Refer to pain specialist or neurosurgeon if 4, 1:

• Progressive neurological deficits despite conservative treatment
• Failure of combination first-line medications after 8-12 weeks
• Severe functional disability affecting quality of life
• Consideration needed for nerve blocks, spinal cord stimulation, or surgical decompression