What medications are recommended for an adult patient with sciatica?

Medications for Sciatica

First-Line Treatment: NSAIDs

Start with continuous NSAID therapy at maximum tolerated doses as the cornerstone of pharmacological management for sciatica. 1, 2

• Naproxen 500 mg twice daily is a preferred option with established dosing for radicular pain 1
• Ibuprofen 400-800 mg three times daily provides alternative NSAID coverage 1
• Meloxicam 7.5-15 mg once daily offers COX-2 selective dosing with potentially fewer gastrointestinal side effects 1
• NSAIDs showed a risk ratio of 1.14 (95% CI 1.03-1.27) for global improvement versus placebo, though pain reduction was not statistically significant 1
• Require at least 8 weeks for adequate trial given the time course to response of approximately 1 month 1
• Monitor for gastrointestinal bleeding, cardiovascular events, and renal dysfunction, especially with long-term use 1, 3

Second-Line: Add Gabapentin for Neuropathic Component

If NSAIDs alone provide inadequate relief after 2-4 weeks, add gabapentin to target the radicular/neuropathic pain component. 1, 2, 3

• Start gabapentin 300 mg at bedtime, then titrate to 300 mg three times daily over 1 week 4
• Target dose is 1200-3600 mg/day in divided doses (typically 600-1200 mg three times daily) 1, 3, 4
• Gabapentin shows small to moderate short-term benefits specifically for radiculopathy 1, 2, 4
• Monitor for sedation, dizziness, and peripheral edema; adjust dosing in renal impairment 1, 3
• Case reports demonstrate rapid pain improvement even after first dose, with complete resolution possible within weeks 4

Third-Line: Tricyclic Antidepressants

For chronic sciatica (>12 weeks) or inadequate response to NSAIDs plus gabapentin, add amitriptyline. 1, 2, 3

• Start amitriptyline 10-25 mg at bedtime 1
• Titrate by 10-25 mg weekly as tolerated 1
• Target dose is 50-75 mg at bedtime 1
• Provides moderate pain relief for chronic low back pain with neuropathic features 1, 2, 3

Adjunctive Therapy for Acute Exacerbations (Short-Term Only)

Consider adding a muscle relaxant for severe acute pain, but limit to maximum 2-3 weeks. 1, 2, 3

• Cyclobenzaprine 5-10 mg three times daily for maximum 2-3 weeks 1, 2, 5
• Cyclobenzaprine acts primarily within the central nervous system at brain stem level, reducing tonic somatic motor activity 5
• Tizanidine 2-4 mg three times daily, can increase to 8 mg three times daily if needed 1
• Both agents cause drowsiness, sedation, and dizziness; warn patients about fall risk 3, 5
• Do not use muscle relaxants beyond 2-3 weeks as no evidence supports longer-term efficacy 3

Medications to AVOID

Systemic corticosteroids are NOT recommended—three higher-quality trials consistently found no clinically significant benefit compared to placebo. 1, 2, 3

• Oral prednisone provides no benefit for sciatica despite widespread historical use 1, 2, 3
• Corticosteroids carry significant risks including hyperglycemia, hypertension, osteoporosis, and immunosuppression 6

Avoid opioids due to limited evidence for short-term modest effects with significant risks. 1, 2, 3

• Opioids have limited efficacy and substantial risks including constipation, sedation, nausea, and potential for abuse/addiction 1, 2, 3
• If absolutely necessary for severe uncontrolled pain, tramadol 50-100 mg every 4-6 hours as needed (maximum 400 mg/day) is preferred over stronger opioids for time-limited trial 1, 3

Benzodiazepines are ineffective for radiculopathy and carry risks of abuse, addiction, and tolerance. 1, 2, 3

Treatment Algorithm

Acute Sciatica (<4 weeks):

1. Start NSAID at appropriate dose (naproxen 500 mg twice daily OR ibuprofen 600-800 mg three times daily OR meloxicam 15 mg daily) 1, 2
2. Add short-term muscle relaxant (cyclobenzaprine 5-10 mg three times daily) for maximum 2-3 weeks if severe pain 1, 2, 3
3. Reassess at 2-4 weeks 1

Persistent Symptoms (4-8 weeks):

1. Continue NSAID if tolerated and showing benefit 1, 2
2. Add gabapentin 300 mg at bedtime, titrate to 300 mg three times daily over 1 week, then increase to target dose of 1200-3600 mg/day in divided doses 1, 2, 3, 4
3. Discontinue muscle relaxant if still being used 3
4. Reassess at 4-6 weeks 3

Chronic Sciatica (>12 weeks):

1. Optimize gabapentin dosing to 1200-3600 mg/day 1, 3
2. Add amitriptyline 10-25 mg at bedtime, titrate by 10-25 mg weekly to target 50-75 mg at bedtime 1, 2, 3
3. Continue NSAID if providing benefit without adverse effects 1, 2
4. Consider referral to pain management or spine specialist if inadequate response after 4-6 weeks of optimized therapy 3

Critical Pitfalls to Avoid

• Do not prescribe systemic corticosteroids—they are ineffective and carry significant risks 1, 2, 3
• Do not use subtherapeutic gabapentin doses—300 mg three times daily is insufficient; target 1200-3600 mg/day 1, 3, 4
• Do not continue muscle relaxants beyond 2-3 weeks—no evidence supports longer-term use 3
• Do not rely on opioids—they have limited efficacy and substantial risks 1, 2, 3
• Do not use NSAIDs indefinitely without reassessing cardiovascular and gastrointestinal risk—use lowest effective dose for shortest necessary period 3