For most back pain, an over-the-counter anti-inflammatory like ibuprofen or naproxen is the best starting point. That’s the consensus across more than 20 clinical practice guidelines worldwide, which consistently recommend NSAIDs as first-line treatment for acute, subacute, and chronic low back pain. But the right medicine depends on what’s causing your pain, how long you’ve had it, and what other health conditions you’re managing.
Why NSAIDs Are the First Choice
Ibuprofen and naproxen work by reducing inflammation at the site of injury, which is what drives most back pain. In studies of acute low back pain, ibuprofen reduced pain intensity from roughly 65 out of 100 down to about 22 within 10 days. These drugs are inexpensive, widely available, and effective for the majority of people with new-onset back pain.
Acetaminophen (Tylenol) is often assumed to be equally effective, but the evidence tells a different story. A major Cochrane review found that acetaminophen at standard doses was no better than a sugar pill for relieving acute low back pain or improving sleep, function, or quality of life. The well-known PACE trial reached the same conclusion: acetaminophen did not change recovery time compared with placebo. That said, combining ibuprofen with acetaminophen may offer faster relief than ibuprofen alone, so acetaminophen still has a supporting role if you’re already taking an anti-inflammatory.
Who Should Avoid NSAIDs
NSAIDs aren’t safe for everyone. The risk of stomach bleeding and kidney problems increases with age, dose, and duration. People 65 and older, those with a history of stomach ulcers, and anyone taking blood thinners or antiplatelet medications face significantly higher risk. Patients on dual antiplatelet therapy after a heart attack who also take an NSAID have roughly double the risk of gastrointestinal bleeding and a 1.4-fold increased risk of cardiovascular events like stroke or another heart attack.
Other factors that raise your risk include taking corticosteroids or certain antidepressants (SSRIs) alongside NSAIDs, having an H. pylori infection, or using NSAIDs at high doses for extended periods. Among common NSAIDs, naproxen carries a somewhat higher GI risk than ibuprofen. If you have stomach concerns but still need an anti-inflammatory, your doctor may recommend a COX-2 selective option, which is gentler on the digestive tract.
Topical Pain Relievers
Topical gels and patches sound appealing because they bypass the stomach. Topical NSAIDs do reach muscle tissue at concentrations similar to oral versions while producing much lower levels in the bloodstream. However, for back pain specifically, the results are underwhelming. A randomized, double-blind trial comparing topical diclofenac gel to oral ibuprofen for acute low back pain found that topical diclofenac was less effective. It also provided no added benefit when combined with oral ibuprofen. The advantage of oral ibuprofen did fade over time, but for the first few days when pain is worst, the oral form performed better.
Lidocaine patches (5% concentration) can provide localized numbing and are applied for up to 12 hours within a 24-hour period, with a maximum of three patches at once. They’re more commonly used for nerve-related pain than for general muscle or joint pain, and they won’t reduce inflammation. For people who truly can’t tolerate oral medications, topical options are a reasonable alternative, but they’re not a first choice for most back pain.
Muscle Relaxants for Spasm-Related Pain
When back pain comes with visible muscle tightness or spasms, a prescription muscle relaxant can help. Common options include cyclobenzaprine and methocarbamol, both of which work by reducing nerve signaling in the brain and spinal cord that triggers involuntary muscle contraction. They don’t act directly on the muscles themselves.
These medications are strictly short-term tools. Cyclobenzaprine is recommended for up to three weeks, and most muscle relaxants have no evidence supporting use beyond that window. They also cause drowsiness, which can be a benefit at night if pain is disrupting your sleep, but a liability during the day. Your doctor will typically prescribe them alongside an NSAID rather than as a standalone treatment.
Oral Steroids for Sciatica
If your back pain radiates down your leg (sciatica) due to a herniated disc pressing on a nerve, your doctor might suggest a short course of oral steroids. A large clinical trial published in JAMA tested a 15-day tapering course of prednisone against placebo in 269 adults with disc-confirmed sciatica. The steroid group showed a meaningful improvement in physical function at both 3 weeks and 1 year. However, it did not reduce pain scores more than placebo at either time point. Nearly half of steroid-treated patients reported at least one side effect at 3 weeks, compared to about 24% in the placebo group, and surgery rates were no different between the two groups at one year.
So oral steroids can help you move and function better during a sciatica flare, but don’t expect them to make the pain itself go away. They’re a targeted option for nerve-related symptoms, not general back soreness.
Medications for Chronic Back Pain
When back pain persists beyond three months, the treatment approach shifts. NSAIDs remain an option, but the focus expands to include medications that target how the nervous system processes pain. Duloxetine, a medication that affects serotonin and norepinephrine signaling in the brain, is one of the few drugs with solid evidence for chronic low back pain. Multiple randomized trials found that 60 mg daily produced statistically significant reductions in both pain severity and disability compared to placebo. Most of these studies ran for 13 to 14 weeks, so you should expect to take it for at least a few months before judging whether it’s working. A dose of 60 mg once daily appears to offer the best balance of effectiveness and tolerability.
Gabapentin and pregabalin are sometimes prescribed for chronic back pain, particularly when there’s a nerve component. Their evidence for general low back pain is weaker than for duloxetine, but they may help if your pain has a burning, shooting, or tingling quality that suggests nerve involvement.
Where Opioids Fit
The CDC’s 2022 prescribing guideline is clear: opioids should not be first-line or routine therapy for back pain at any stage. Non-opioid treatments are at least as effective as opioids for low back pain, and the risks of dependence, tolerance, and overdose are substantial. Opioids are reserved for situations where NSAIDs and other therapies are contraindicated or have failed, and where the expected benefits genuinely outweigh the risks. For subacute and chronic pain, nonopioid therapies are explicitly preferred. If your provider suggests trying opioids for back pain without first exhausting other options, it’s reasonable to ask about alternatives.
Supplements and Natural Options
Turmeric (curcumin) has generated interest for pain and inflammation, but the clinical picture is thin. Most studies have been conducted in animals rather than humans, and the research that does exist focuses on neuropathic pain models rather than typical back pain. Curcumin has GRAS (Generally Recognized as Safe) status, so it’s unlikely to cause harm, but there’s no strong human evidence that it will meaningfully reduce your back pain. Magnesium supplements are similarly popular but lack clinical trial data specific to back pain. Neither should replace proven treatments, though they’re unlikely to interfere with them either.
Matching Medicine to Your Type of Pain
The practical approach depends on your situation. For a new episode of back pain without leg symptoms, start with an NSAID like ibuprofen taken at regular intervals for a few days rather than waiting until pain peaks. You can add acetaminophen between NSAID doses for additional relief. If muscle spasms are prominent, ask about a short course of a muscle relaxant, especially for nighttime use.
For sciatica with leg pain, NSAIDs are still the starting point, with oral steroids as a second-tier option if function is significantly impaired. For chronic pain lasting beyond three months, duloxetine becomes a strong option alongside continued exercise, which every major guideline recommends regardless of pain duration. Topical treatments are best reserved for people who can’t take oral anti-inflammatories due to stomach, kidney, or cardiovascular concerns.