Best Pain Medicine for Upper Back Pain
For acute upper back pain, NSAIDs (such as ibuprofen) are the first-line medication choice, providing small to moderate short-term pain relief with moderate-quality evidence supporting their efficacy. 1
First-Line Pharmacologic Treatment
- NSAIDs (ibuprofen, naproxen, diclofenac) are the recommended initial medication for upper back pain, with evidence showing a mean difference in pain intensity of -3.30 points on a 0-100 scale compared to placebo 2
- Ibuprofen specifically has demonstrated analgesic and antipyretic activity through prostaglandin synthetase inhibition, with clinical studies showing it is comparable to aspirin but with significantly reduced gastrointestinal side effects 3
- Acetaminophen is an alternative first-line option with a more favorable safety profile, particularly for elderly patients, though recent evidence from 2017 shows it is actually ineffective for acute low back pain 2, 1
When First-Line Treatment Is Insufficient
- Skeletal muscle relaxants (cyclobenzaprine, methocarbamol) can be added if pain persists, with moderate-quality evidence showing improved short-term pain relief after 2-7 days 1
- Cyclobenzaprine 5-10 mg three times daily has the strongest evidence among muscle relaxants, with pooled data from 20 trials (n=1,553) demonstrating superiority to placebo for short-term global improvement 4, 5
- Muscle relaxants should only be used for short-term treatment (≤1-2 weeks) as all trials were limited to ≤2 weeks duration, and they cause sedation, drowsiness, and dizziness 4, 5
Important Caveats and Pitfalls
- Avoid acetaminophen as monotherapy for acute back pain based on 2017 American College of Physicians guidelines showing it is ineffective, despite older 2007 recommendations that supported its use 2
- Do not prescribe systemic corticosteroids as low-quality evidence shows no difference in pain or function compared to placebo 1
- NSAIDs should be used with caution in patients with history of gastrointestinal bleeding, cardiovascular disease, or chronic renal disease 6
- Reserve opioids only for severe, disabling pain not controlled with acetaminophen and NSAIDs, and only after carefully weighing potential benefits and harms 1
Special Populations
- For elderly patients, acetaminophen may be preferred over NSAIDs due to lower risk of adverse effects, though efficacy is limited 1
- In patients with hepatic impairment, cyclobenzaprine should be initiated at 5 mg and titrated slowly upward, as both AUC and Cmax are approximately double in hepatic impairment 5