Medications for Sciatica
For sciatica, start with NSAIDs as first-line therapy, then add gabapentin to target the neuropathic component if NSAIDs alone are insufficient, and avoid systemic corticosteroids entirely as they provide no benefit. 1
First-Line Treatment: NSAIDs
NSAIDs are the initial pharmacological treatment for sciatica, showing a risk ratio of 1.14 (95% CI 1.03-1.27) for global improvement versus placebo, though pain reduction itself was not statistically significant (MD -4.56,95% CI -11.11 to 1.99). 2
The American College of Physicians recommends continuous NSAID dosing over on-demand dosing for inflammatory conditions including sciatica. 1
Specific NSAID dosing regimens:
NSAIDs require at least 8 weeks for full therapeutic effect, with time to response approximately 1 month. 1
Monitor for gastrointestinal bleeding, cardiovascular events (especially with longer use and higher doses), and renal dysfunction. 3, 4
Second-Line: Add Gabapentin for Neuropathic Component
Gabapentin is particularly effective for the radicular/neuropathic pain component of sciatica, showing small to moderate short-term benefits specifically for radiculopathy. 1, 3
The American College of Physicians recommends adding gabapentin or pregabalin when NSAIDs alone provide inadequate response, targeting the neuropathic component that NSAIDs cannot address. 1
Gabapentin dosing: Start low and titrate up to 1200-3600 mg/day divided in three doses. 3
Sciatica represents a "mixed pain syndrome" with both nociceptive and neuropathic components—NSAIDs address only the nociceptive component, which is why combination therapy with gabapentin is often necessary. 5
Monitor for sedation, dizziness, and peripheral edema; adjust dosing in renal impairment. 1, 3
Third-Line: Tricyclic Antidepressants
For chronic sciatica not responding to NSAIDs plus gabapentin, add amitriptyline, which provides moderate pain relief for chronic low back pain with good supporting evidence. 1, 3
Amitriptyline dosing: Start 10-25 mg at bedtime, titrate by 10-25 mg weekly as tolerated, target dose 50-75 mg at bedtime. 1
Adjunctive Therapy for Acute Exacerbations
Muscle relaxants provide short-term benefit (2-3 weeks maximum) for acute pain:
Tizanidine combined with NSAIDs provides consistently greater short-term pain relief than NSAIDs alone in high-quality trials, though it increases CNS adverse events (RR 2.44). 4, 6
All muscle relaxants cause sedation and should be limited to short-term use only. 6
Tramadol 50-100 mg every 4-6 hours as needed (maximum 400 mg/day) can be considered for severe pain, though it was only moderately more effective than placebo in one trial. 4, 1
Medications to AVOID
Systemic corticosteroids are NOT recommended for sciatica—three higher-quality trials consistently found no clinically significant benefit compared to placebo, whether given parenterally (single injection) or as a short oral taper. 4, 1, 3
Avoid opioids due to limited evidence for short-term modest effects with significant risks including constipation, sedation, nausea, and potential for abuse/addiction. 4, 1, 3
Benzodiazepines are ineffective for radiculopathy based on low-quality evidence and carry risks of abuse, addiction, and tolerance. 1, 3
Pregabalin shows no benefit for chronic nonradicular back pain and may actually worsen function—it is not recommended for sciatica despite FDA approval for other neuropathic pain conditions. 3
Treatment Algorithm
Start with continuous NSAID therapy (naproxen 500 mg twice daily or ibuprofen 400-800 mg three times daily) 1
If inadequate response after 1-2 weeks, add gabapentin starting low and titrating to 1200-3600 mg/day 1, 3
For acute severe exacerbations, add short-term tizanidine (2-4 mg three times daily for maximum 2-3 weeks) 1, 6
If pain persists beyond 6-8 weeks, add amitriptyline 10-25 mg at bedtime, titrating to 50-75 mg 1, 3
Reassess at 8 weeks—if no improvement, consider imaging (MRI preferred) and specialist referral 7
Critical Pitfalls to Avoid
Do not prescribe systemic corticosteroids—they are ineffective and expose patients to unnecessary risks including hyperglycemia. 4, 1
Do not use muscle relaxants beyond 2-3 weeks—no evidence supports longer-term use and they cause significant sedation. 1, 6
Do not prescribe opioids as first-line therapy—guidelines from the American College of Physicians and American Pain Society recommend opioids only for severe, disabling pain not controlled by other options. 4
Do not expect immediate pain relief from NSAIDs—allow at least 8 weeks for full therapeutic effect. 1
Do not use pregabalin for sciatica—despite its FDA approval for other neuropathic pain conditions, it shows no benefit and may worsen function in back pain. 3