What oral medications are appropriate for treating uncomplicated left‑sciatica?

Oral Medications for Left Sciatica Pain

Start with NSAIDs as first-line therapy, add gabapentin for the neuropathic component if NSAIDs alone are insufficient, and consider adding a tricyclic antidepressant if pain persists after 4-6 weeks of optimized combination therapy.

First-Line: NSAIDs

• Initiate continuous NSAID therapy rather than on-demand dosing for inflammatory back conditions including sciatica 1
• Naproxen 500 mg twice daily or ibuprofen 600-800 mg three times daily are preferred initial choices 1, 2
• NSAIDs show a risk ratio of 1.14 (95% CI 1.03-1.27) for global improvement versus placebo, though pain reduction benefits are modest 1, 3
• Use the lowest effective dose for the shortest necessary period, monitoring for gastrointestinal bleeding, cardiovascular events, and renal dysfunction 4, 1
• Meloxicam 7.5-15 mg once daily is an alternative COX-2 selective NSAID with convenient once-daily dosing 1
• Prescribe a proton pump inhibitor alongside NSAIDs for patients with gastrointestinal risk factors 4

Second-Line: Add Gabapentin for Neuropathic Component

• Add gabapentin when NSAIDs alone provide insufficient relief, as it is particularly effective for radicular pain/sciatica with small to moderate short-term benefits 1, 2, 5
• Start gabapentin at 300 mg once daily at bedtime, then titrate to 300 mg three times daily (900 mg/day) over 1-2 weeks 1, 2
• Target therapeutic dose is 1200-3600 mg/day divided into 2-3 doses for adequate neuropathic pain control 1, 2
• Monitor for sedation, dizziness, and peripheral edema; adjust dosing in renal impairment 1, 2
• Allow at least 4-6 weeks at therapeutic doses before concluding treatment failure 2, 5

Third-Line: Tricyclic Antidepressants

• Add amitriptyline 10-25 mg at bedtime if pain persists after 4-6 weeks of optimized gabapentin plus NSAIDs 1, 2, 5
• Titrate by 10-25 mg weekly as tolerated to a target dose of 50-75 mg at bedtime 1
• Tricyclic antidepressants provide moderate pain relief for chronic low back pain with good supporting evidence 1, 2, 5
• Nortriptyline 10-25 mg nightly is preferred over amitriptyline in elderly patients due to fewer anticholinergic side effects 2
• The combination of nortriptyline and gabapentin is superior to either medication alone for neuropathic pain 2

Alternative: Duloxetine

• Duloxetine 30-60 mg daily is an alternative to tricyclic antidepressants, particularly when depression coexists 2, 5
• Start with 30 mg daily, increasing to 60 mg daily after 1 week if tolerated 2
• Duloxetine provides small but consistent improvements in pain intensity (0.60-0.79 points on 0-10 scale) and functional outcomes 2

Adjunctive Therapy for Acute Exacerbations (Short-Term Only)

• Cyclobenzaprine 5-10 mg three times daily for maximum 2-3 weeks for severe acute pain 1, 2
• Tizanidine 2-4 mg three times daily, can increase to 8 mg three times daily 1
• Muscle relaxants should not be used beyond 2 weeks and have no role in chronic sciatica 2
• Tramadol 50-100 mg every 4-6 hours as needed (maximum 400 mg/day) only as a time-limited trial if severe pain is uncontrolled 1, 5

Medications to AVOID

• Systemic corticosteroids are NOT recommended—three higher-quality trials consistently found no clinically significant benefit compared to placebo for sciatica 4, 1, 2
• Avoid opioids (except tramadol for short-term use) due to limited evidence for modest short-term effects with significant risks including constipation, sedation, nausea, and potential for abuse/addiction 1, 2, 5
• Benzodiazepines are ineffective for radiculopathy and substantially increase fall risk, especially in elderly patients 1, 2
• Codeine and propoxyphene show poor efficacy and unfavorable side effect profiles 6

Treatment Algorithm

1. Week 0-2: Start naproxen 500 mg twice daily or ibuprofen 600-800 mg three times daily 1, 2
2. Week 2-4: If insufficient relief, add gabapentin 300 mg at bedtime, titrate to 300 mg three times daily 1, 2
3. Week 4-8: Increase gabapentin to 1200-1800 mg/day in divided doses if tolerated but response insufficient 1, 2
4. Week 8-12: If pain persists, add amitriptyline 10-25 mg at bedtime or duloxetine 30-60 mg daily 1, 2, 5
5. Beyond 12 weeks: Reassess for specialist referral if uncontrolled despite optimized medications 2, 5

Critical Monitoring Parameters

• NSAIDs: Monitor blood pressure, renal function, gastrointestinal symptoms, and cardiovascular risk factors 4, 1
• Gabapentin: Monitor for sedation, dizziness, peripheral edema, and adjust for renal impairment 1, 2
• Tricyclic antidepressants: Monitor for anticholinergic effects (dry mouth, urinary retention, constipation), sedation, and orthostatic hypotension 2
• Functional improvement: Use validated measures to assess treatment response, not just pain scores 5

Common Pitfalls to Avoid

• Do not use subtherapeutic gabapentin doses (e.g., 100-300 mg/day)—these provide no meaningful analgesic effect for radiculopathy 2
• Do not prescribe muscle relaxants for chronic sciatica—no evidence supports efficacy beyond 2 weeks 2
• Do not combine multiple sedating medications without careful fall risk assessment, especially in elderly patients 2
• Do not continue ineffective treatments—reassess at 4-6 weeks and adjust or refer if no improvement 2, 5
• Allow adequate trial duration—NSAIDs require at least 8 weeks for full effect 1