What medications are used to treat chronic neck pain?

Medications for Chronic Neck Pain

First-Line Pharmacologic Treatment

For chronic neck pain, NSAIDs (such as ibuprofen 400-800 mg three times daily) should be initiated first, though evidence shows only small to moderate short-term pain relief. 1, 2

• NSAIDs provide modest benefit for chronic musculoskeletal pain, with effect sizes of 0.5-0.8 and pain improvement of 10-20 points on a 100-point scale 1
• Ibuprofen is available in 400 mg, 600 mg, and 800 mg formulations, typically dosed three times daily 3
• Important caveat: NSAIDs should be avoided in patients with Ehlers-Danlos syndrome or significant gastrointestinal concerns, as they can worsen GI symptoms 4

Second-Line Options

Muscle Relaxants for Acute Exacerbations

Cyclobenzaprine 5 mg three times daily is effective for acute neck pain episodes but causes significant sedation. 2, 5

• Start with 5 mg dose, particularly in elderly patients, and titrate slowly upward if needed 5
• Provides short-term pain relief but drowsiness occurs frequently 1
• Should be used for brief periods during acute flares, not as chronic therapy 2

Combination Therapy for Persistent Pain

When NSAIDs alone are insufficient, add tramadol 37.5 mg plus acetaminophen 325 mg twice daily. 6

• This combination was effective in reducing pain to acceptable levels (NRS ≤5) in 68.2% of patients with chronic neck pain over 2 weeks 6
• Acetaminophen alone is safe but has limited efficacy for chronic pain 1, 4

Neuropathic Pain Component

If neuropathic features are present (burning, shooting pain, numbness), initiate gabapentin as first-line treatment, titrating to 2400 mg daily in divided doses. 1, 4

• Start with 100-200 mg daily and escalate incrementally to monitor for side effects (somnolence, dizziness, mental clouding) 1
• Pregabalin 75-300 mg twice daily is an alternative with easier titration, starting at 25-50 mg daily 1
• Nearly half of patients with chronic neck pain have mixed neuropathic-nociceptive or predominantly neuropathic symptoms, making gabapentinoids particularly relevant 2

Alternative Neuropathic Agents

If gabapentin fails, consider tricyclic antidepressants (amitriptyline) starting at low doses and titrating to 75-100 mg if tolerated. 1, 4

• Provides small to moderate benefit for chronic pain with effect size of 0.5-0.8 1
• Particularly useful in patients with comorbid depression or sleep disturbances 1
• SNRIs (duloxetine) can be considered as third-line option 1

Topical Therapies

Topical NSAIDs (diclofenac) or lidocaine patches should be considered early due to high safety profile from low systemic absorption. 1

• Particularly appropriate for elderly patients or those with multiple comorbidities 1
• Can be used in combination with oral medications 1

Opioids: Use with Extreme Caution

Opioids should be avoided for chronic neck pain except in rare circumstances, as evidence is limited to short-term modest effects and serious harms are well-documented. 1, 4

• The 2022 CDC guideline emphasizes nonopioid therapies as preferred for chronic pain 1
• If opioids are considered, they should only be used short-term and at the lowest effective dose 1
• Never prescribe opioids for chronic pain in patients with Ehlers-Danlos syndrome 4

Medications to Avoid

Acetaminophen alone is ineffective for chronic neck pain and should not be used as monotherapy. 1

Benzodiazepines are ineffective for chronic musculoskeletal pain and carry significant risks. 1

Systemic corticosteroids are ineffective for chronic neck pain. 1

Treatment Algorithm

1. Start with NSAIDs (ibuprofen 400-800 mg TID) for 2 weeks 1, 2
2. If inadequate response, add tramadol/acetaminophen combination (37.5/325 mg BID) 6
3. If neuropathic features present, initiate gabapentin (titrate to 2400 mg/day) instead of or in addition to NSAIDs 1
4. If gabapentin fails, trial tricyclic antidepressant (amitriptyline, titrate to 75-100 mg) 1
5. Consider topical agents at any stage, especially in elderly 1
6. If oral medications fail after 2-4 weeks, refer for interventional procedures (cervical medial branch blocks) 6

Critical Pitfalls

• Most medication benefits are small to moderate and primarily short-term; functional improvements are generally smaller than pain relief 1
• Patients with straight or sigmoid lateral cervical curvature are more difficult to manage with oral medications alone and may require earlier interventional treatment 6
• Always integrate medications with nonpharmacologic therapies (exercise, physical therapy, cognitive behavioral therapy) as medication alone is insufficient 1