What medications are used to treat radiculopathy?

Medications for Radiculopathy

Start with NSAIDs (naproxen) as first-line therapy, add gabapentin for neuropathic pain if needed, and avoid oral corticosteroids entirely as they provide no benefit over placebo. 1, 2

First-Line Treatment: NSAIDs

• Naproxen is the recommended first-line medication for radiculopathy due to moderate efficacy and superior safety profile compared to other options 1
• NSAIDs target the inflammatory component of radicular pain 1, 3
• Use the lowest effective dose to minimize gastrointestinal bleeding, perforation, renal toxicity, and cardiovascular risks including heart attack and stroke 1, 4
• NSAIDs increase cardiovascular risk with longer use and higher doses 5, 4
• Avoid NSAIDs in patients with history of GI bleeding, renal disease, or cardiovascular disease 4

Second-Line: Gabapentin for Neuropathic Component

• Add gabapentin (1200-3600 mg/day titrated) when neuropathic radicular pain persists despite NSAIDs 1, 3
• Gabapentin shows small to moderate short-term benefits specifically for radiculopathy 1, 3
• The American Academy of Neurology recommends gabapentin as a reasonable option for neuropathic pain, though evidence quality is moderate 1
• Start with lower doses and titrate gradually, especially in elderly patients, to minimize sedation, dizziness, and peripheral edema 3
• Adjust dosing in renal impairment 3
• Gabapentin is NOT FDA-approved for radiculopathy; use only time-limited courses 1

Alternative Neuropathic Pain Medications

• Tricyclic antidepressants (amitriptyline) provide moderate pain relief for chronic low back pain with radicular features 3
• Duloxetine shows small improvements in pain intensity and function, particularly useful if depression coexists 3
• The American Academy of Neurology considers gabapentinoids, SNRIs, and tricyclic antidepressants therapeutically equivalent for neuropathic pain 1
• Combination therapy may be superior to monotherapy for mixed pain syndromes 1, 3

Muscle Relaxants (Short-Term Only)

• Cyclobenzaprine may be added for acute exacerbations (≤1-2 weeks only) for muscle spasm relief 3
• Cyclobenzaprine has the strongest evidence among muscle relaxants, with 20 trials (n=1553) showing superiority to placebo for short-term global improvement 3
• Never use muscle relaxants beyond 2 weeks—no evidence supports efficacy in chronic pain 3
• Causes dose-related sedation, dizziness, and fall risk, particularly dangerous in elderly patients 3
• Avoid in older adults due to lack of efficacy evidence and significant adverse effects 3

Medications to AVOID

Oral Corticosteroids (Prednisone/Medrol Dose Packs)

• Do NOT prescribe oral corticosteroids for radiculopathy—six trials consistently show no benefit over placebo 2
• Oral prednisone causes significant harms: insomnia (26% vs 10%), nervousness (18% vs 8%), increased appetite (22% vs 10%), and any adverse event (49% vs 24%) 2
• A 3-week prednisone course for spinal stenosis showed no differences from placebo in pain or disability through 12 weeks 2
• Oral corticosteroids do not reduce need for spine surgery 2
• This contradicts one older 2013 cervical radiculopathy trial showing benefit 6, but the 2025 American College of Physicians guideline based on six pooled trials takes precedence 2

Other Medications to Avoid

• Benzodiazepines are ineffective for radiculopathy and carry risks of abuse, addiction, and tolerance 3
• Pregabalin shows no benefit for nonradicular back pain and may worsen function 3
• Systemic corticosteroids (oral or IV) are not recommended by the American College of Physicians 3, 2

Treatment Algorithm

1. Start with naproxen (lowest effective dose) to address inflammatory component 1
2. Add gabapentin (titrate to 1200-3600 mg/day) if neuropathic pain persists after 1-2 weeks 1, 3
3. Consider adding tricyclic antidepressant or duloxetine if response insufficient 3
4. For acute severe exacerbations only, add cyclobenzaprine for ≤1-2 weeks 3
5. Reassess efficacy and side effects regularly; discontinue medications showing no benefit 1, 3
6. Reserve extended medication courses only for patients with clear continued benefits without major adverse events 1

Critical Pitfalls to Avoid

• Do not prescribe oral corticosteroids (Medrol dose packs)—they cause harm without benefit 2
• Do not use muscle relaxants beyond 2 weeks or for chronic pain 3
• Do not use gabapentin or pregabalin long-term without documented benefit, as neither is FDA-approved for this indication 1
• Do not combine NSAIDs with corticosteroids—this dramatically increases GI bleeding risk 7
• Most patients with lumbar disc herniation improve within 4 weeks with conservative management 2
• Radiculopathy is relatively refractory to medications compared to other neuropathic pain conditions 1