For most types of back pain, an over-the-counter anti-inflammatory like ibuprofen or naproxen is the best first choice. The American College of Physicians recommends these as the go-to medication for both acute and chronic low back pain when non-drug options aren’t enough. But “best” depends on how long your pain has lasted, what’s causing it, and your overall health, so the answer gets more nuanced from there.
Why Anti-Inflammatories Come Out on Top
NSAIDs (ibuprofen, naproxen, aspirin) work by reducing inflammation at the site of pain, which makes them a natural fit for back pain since most episodes involve inflamed muscles, joints, or ligaments. They consistently outperform other options in clinical trials. In one randomized study comparing oral ibuprofen to a topical anti-inflammatory gel for acute low back pain, the ibuprofen group improved significantly more within two days, with pain scores dropping by about 10 points on a 100-point scale compared to roughly 6 points for the topical gel alone.
Naproxen has a longer duration of action than ibuprofen, so you take it less frequently, typically every 8 to 12 hours versus every 4 to 6 hours. Both are effective. The choice often comes down to personal preference and how your stomach handles each one.
Where Acetaminophen Fits In
Acetaminophen (Tylenol) is a pain reliever but not an anti-inflammatory, which limits its usefulness for back pain specifically. It can take the edge off, but it doesn’t address the underlying inflammation driving most back pain episodes. A randomized trial of 120 emergency department patients with acute low back pain found that adding acetaminophen to ibuprofen produced no additional benefit. At one week, 28% of patients still reported moderate or severe pain in both groups, whether they took ibuprofen alone or ibuprofen plus acetaminophen.
That said, acetaminophen has a role for people who can’t take anti-inflammatories due to stomach, heart, or kidney concerns. It’s gentler on the digestive system and doesn’t affect blood pressure. If you do use it, keep your total daily intake below 3,000 mg when possible. The absolute ceiling for healthy adults is 4,000 mg from all sources in 24 hours, but doses near that limit can still stress the liver, especially with regular use. Be aware that acetaminophen hides in many combination products (cold medicines, sleep aids, prescription painkillers), so it’s easy to accidentally double up.
Muscle Relaxants: Limited Benefit
If your back pain involves tight, spasming muscles, your doctor might suggest a muscle relaxant alongside an anti-inflammatory. These are prescription-only in the U.S. A large meta-analysis published in The BMJ, covering 16 trials and over 4,500 participants, found that non-benzodiazepine muscle relaxants reduced pain by about 8 points on a 100-point scale within two weeks. That’s a statistically measurable difference, but it falls below the threshold most researchers consider clinically meaningful, meaning patients often can’t feel a noticeable improvement.
Beyond two weeks, the benefit disappeared entirely. Muscle relaxants also caused drowsiness and dizziness at higher rates than placebo, and they did not improve functional disability at any time point. They’re best reserved for the first few days of a severe flare when muscle spasm is the dominant problem, not as an ongoing treatment.
Acute Back Pain vs. Chronic Back Pain
Most acute back pain (lasting less than four weeks) improves on its own regardless of treatment. The American College of Physicians actually recommends trying non-drug approaches first for acute episodes: heat therapy has moderate-quality evidence supporting it, and massage, acupuncture, and spinal manipulation have lower-quality but still positive evidence. If you want medication on top of those, NSAIDs or a short course of a muscle relaxant are the recommended options.
Chronic back pain, lasting 12 weeks or more, is a different situation. NSAIDs remain the first-line medication, but when they aren’t providing enough relief, the guidelines shift. Second-line options include duloxetine, an antidepressant that also dampens pain signaling in the nervous system, and tramadol, a low-potency opioid-like pain reliever. Certain older antidepressants (tricyclics) also have good evidence for chronic back pain relief, likely because they alter how the brain processes persistent pain signals. These are all prescription medications that require a conversation with your doctor about risks and benefits.
Nerve Pain Medications Don’t Help Most Back Pain
If your back pain shoots down your leg (often called sciatica or radicular pain), you might assume a nerve pain medication would be the answer. The evidence says otherwise. A 12-week randomized trial of 108 patients with chronic low back pain compared gabapentin (a common nerve pain drug) to placebo. Both groups saw pain drop by about 30% from baseline, with no difference between them. Gabapentin was equally ineffective whether pain radiated into the leg or stayed localized to the back. Patients on gabapentin did, however, experience more fatigue, dry mouth, trouble concentrating, memory difficulties, and balance problems.
Topical Gels and Creams
Topical anti-inflammatory gels (like diclofenac gel, available over the counter as Voltaren) appeal to people who want to avoid swallowing pills. They do deliver anti-inflammatory medication directly to the tissue, and they cause fewer stomach side effects than oral NSAIDs. However, for back pain specifically, they appear to be less effective than oral options. The muscles and structures causing low back pain sit deeper than, say, a sore knee or wrist, so the medication has a harder time penetrating to the source. Topical gels are a reasonable option if oral NSAIDs bother your stomach, but don’t expect the same level of relief.
Who Should Avoid NSAIDs
NSAIDs are effective, but they carry real risks for certain people. The three main concerns are your stomach, your heart, and your kidneys.
- Stomach and digestive risk: NSAIDs can cause ulcers and gastrointestinal bleeding, particularly in people over 65, those with a history of ulcers, and anyone taking blood thinners, corticosteroids, or certain antidepressants (SSRIs). Using multiple NSAIDs at once or taking high doses increases the danger further.
- Cardiovascular risk: NSAIDs raise both systolic and diastolic blood pressure and can worsen heart failure. People with established heart disease or significant cardiovascular risk factors face the greatest danger.
- Kidney risk: NSAIDs interfere with how your kidneys regulate fluid and blood pressure. People with existing kidney problems, or those who are dehydrated, should be especially cautious.
If any of these apply to you, acetaminophen (within the daily limits above), topical treatments, or non-drug therapies may be safer starting points. For chronic pain in higher-risk patients, your doctor may consider duloxetine or other prescription alternatives that don’t carry the same cardiovascular and GI risks.
A Practical Approach
For a new episode of back pain, start with heat and gentle movement, and add ibuprofen (up to 1,200 mg per day over the counter, or higher doses with medical guidance) or naproxen if you need medication. Take the lowest effective dose for the shortest time necessary. If your pain hasn’t improved meaningfully after a week or two, or if it’s been lingering for months, that’s the point where prescription options and a more structured treatment plan come into play. The key takeaway from the research is that anti-inflammatories consistently outperform every other class of pain reliever for back pain, and stacking additional medications on top of them rarely adds meaningful benefit.