What are the recommended pain relievers for a patient with radiculopathy?

Pain Relief for Radiculopathy

Start with NSAIDs (naproxen or ibuprofen) combined with gabapentin as first-line therapy for radiculopathy. 1, 2

First-Line Pharmacological Approach

NSAIDs should be initiated first at the lowest effective dose to target the inflammatory component of radicular pain. 1, 3 Naproxen is specifically recommended due to moderate efficacy and a better safety profile compared to other options. 1, 3 However, evidence shows that NSAIDs alone produce only small and inconsistent effects on radicular pain. 4, 2

Add gabapentin to NSAIDs to address the neuropathic component of radiculopathy. 1, 2, 3 Gabapentin demonstrates small to moderate short-term benefits specifically for radicular pain and may improve quality of life. 4, 1, 3 Start with low doses and titrate gradually to 1200-3600 mg/day, particularly in older patients or those with renal impairment. 2, 3 Monitor for sedation, dizziness, and peripheral edema. 2

The combination approach is superior because NSAIDs target inflammation while gabapentin addresses nerve pain—the two primary pain mechanisms in radiculopathy. 1, 2, 3

Second-Line Options

If pain persists after 2-4 weeks on NSAIDs plus gabapentin:

• Add tricyclic antidepressants (amitriptyline) for chronic radiculopathy, which show small to moderate benefits for neuropathic pain. 4, 3
• Consider duloxetine as an alternative SNRI option with established efficacy in neuropathic pain conditions. 4, 3
• For acute severe muscle spasm only: Add tizanidine 2-4 mg, titrating as needed, but limit use to 7-14 days maximum. 2 Other muscle relaxants like cyclobenzaprine may be used short-term (≤1-2 weeks) for acute exacerbations. 1

Medications to AVOID

Do NOT use systemic corticosteroids for radiculopathy—six trials consistently showed no benefit over placebo, and oral prednisone increases adverse events without pain relief. 4, 1, 2

Avoid benzodiazepines—they show no functional improvement, may cause more pain compared to placebo, and carry significant risks for abuse, addiction, and tolerance. 4, 1, 2

Do not use pregabalin—it shows no benefit for radiculopathy and may actually worsen function. 1, 2

Avoid acetaminophen—no studies have evaluated its efficacy specifically for radicular low back pain. 4

Critical Dosing and Safety Considerations

NSAIDs: Use the lowest effective dose for the shortest duration to minimize gastrointestinal bleeding and cardiovascular risks, which increase with longer use and higher doses. 2, 5 Avoid in patients with recent or planned cardiac surgery. 5

Gabapentin: Not FDA-approved for radiculopathy; use as off-label therapy with time-limited courses. 4, 3 Adjust dosing in renal impairment to prevent accumulation and toxicity. 2

Muscle relaxants: Never extend beyond 1-2 weeks—no evidence supports efficacy beyond this timeframe, and risks include sedation and hypotension (especially with tizanidine). 1, 2

Treatment Algorithm

1. Week 0: Start naproxen (lowest effective dose) + gabapentin (start low, titrate to 1200-3600 mg/day). 1, 2, 3
2. If severe acute muscle spasm: Add tizanidine 2-4 mg for ≤2 weeks only. 1, 2
3. Week 2-4: Reassess efficacy and side effects. If insufficient response, add tricyclic antidepressant (amitriptyline) or duloxetine. 1, 2
4. Ongoing: Discontinue medications not providing benefit. Reserve extended courses only for patients showing clear continued benefits without major adverse events. 4, 3

Special Populations

Pregnancy: Amitriptyline, duloxetine, and venlafaxine are considered safe. 1 Avoid muscle relaxants and systemic corticosteroids. 1 Gabapentin safety data in pregnancy is limited despite being first-line in non-pregnant patients. 1

Older adults: Use lower starting doses of gabapentin with more gradual titration, as adverse effects may be more severe. 3

Important Caveats

Most medication trials were short-term (≤4 weeks) with limited data on long-term efficacy or serious harms. 4 Radiculopathy appears relatively refractory to existing medications compared to other neuropathic pain conditions. 3 The evidence base is stronger for lumbar than cervical radiculopathy. 3, 6 Patients should be reassured that most cases resolve regardless of treatment type, though medications can provide symptomatic relief during recovery. 7, 6