What is the first-line medication for a patient presenting with radiculopathy?

First-Line Medication for Radiculopathy

For radiculopathy, start with NSAIDs (such as naproxen) as first-line therapy to target the inflammatory component, and add gabapentin for the neuropathic component of radicular pain. 1, 2

Initial Pharmacological Approach

NSAIDs as Foundation

• NSAIDs like naproxen should be initiated first due to moderate efficacy and better safety profile compared to other options 2
• NSAIDs primarily target the inflammatory component of radicular pain 1
• Use the lowest effective dose to minimize gastrointestinal and cardiovascular risks 2, 3
• The American College of Physicians recommends NSAIDs as initial treatment for chronic low back pain with moderate short-term efficacy 1

Adding Gabapentin for Neuropathic Component

• Gabapentin shows small to moderate short-term benefits specifically for radicular pain and should be added to NSAIDs for the neuropathic component 1, 2
• Titrate gabapentin up to 1200-3600 mg/day divided in doses 1, 2
• Gabapentin is particularly effective for radiculopathy compared to nonradicular back pain 1
• The American Academy of Neurology suggests gabapentin may provide benefits in pain alleviation and improved quality of life in chronic radiculopathy 2

Treatment Algorithm

1. Start with naproxen at the lowest effective dose 2
2. Add gabapentin if pain persists, starting low and titrating gradually (especially in older patients) 2
3. For acute exacerbations with severe muscle spasm, consider adding cyclobenzaprine for short-term use (≤1-2 weeks only) 1
4. If insufficient response, consider adding tricyclic antidepressants (amitriptyline) or duloxetine 1
5. Reassess regularly for efficacy and side effects; use time-limited courses 1, 2

Critical Pitfalls to Avoid

Medications That Don't Work

• Do NOT use systemic corticosteroids - they are ineffective compared to placebo for radiculopathy 1, 4
• Avoid benzodiazepines - ineffective for radiculopathy based on low-quality evidence 1
• Pregabalin shows no benefit for chronic nonradicular back pain and may worsen function 1

Duration Limitations

• Muscle relaxants should never be used beyond 1-2 weeks - no evidence supports efficacy beyond this timeframe 1
• Do not use muscle relaxants for chronic low back pain (>12 weeks duration) 1
• All skeletal muscle relaxant trials were ≤2 weeks duration 1

Safety Concerns

• Monitor gabapentin for sedation, dizziness, and peripheral edema; adjust dosing in renal impairment 1
• NSAIDs increase cardiovascular risk with longer use and higher doses, including heart attack and stroke 1, 3
• Muscle relaxants cause significant CNS effects including drowsiness, fatigue, and dizziness - particularly dangerous in elderly patients due to fall risk 1

Evidence Quality Considerations

The recommendation for NSAIDs plus gabapentin comes from the most recent (2025) American College of Physicians guidelines 1, 2, which supersede the older 2007 guidelines 5. However, it's important to note that radiculopathy appears relatively refractory to existing medications with limited high-quality evidence 2. Most patients with lumbar disc herniation and radiculopathy improve within the first 4 weeks with noninvasive management 5, so the natural history is favorable even without aggressive pharmacological intervention.

Special Population: Pregnancy

• For pregnant patients with radiculopathy, amitriptyline, duloxetine, and venlafaxine are considered safe 4
• Gabapentin is not mentioned as safe in pregnancy despite being first-line in non-pregnant patients 4
• Avoid muscle relaxants and systemic corticosteroids during pregnancy 4