Medications for Spine Pain: A review of the different classes, how they work, and common side effects

Anti inflammatory drugs (NSAIDS)

Neck and back pain are extremely common conditions affecting up to 80% of people during their lifetimes. Fortunately, there are several treatment options available to alleviate the symptoms of spine pain, with medication being one of the most commonly used and often considered the first line treatment. 

There are a variety of medications that can be used to treat spine pain, each with their own unique mechanism of action and side effect profile. 

Choosing the Right Medication(s)

There are several factors that healthcare professionals consider when choosing a medication to treat back pain. Some of these factors include:

  1. Severity of the pain: Over-the-counter pain relievers may be sufficient for mild to moderate pain, while prescription medications may be necessary for more severe pain.
  2. Underlying cause of the pain: Different medications may be more effective for specific causes of back pain. For example, nonsteroidal anti-inflammatory drugs (NSAIDs) may be more effective for back pain caused by inflammation, while muscle relaxants may be more effective for pain caused by muscle spasms.
  3. Coexisting medical conditions: If a patient has a medical condition such as gastric ulcers or renal failure, certain medications may not be suitable and alternative treatments must be considered.
  4. Allergies: Any known allergies or sensitivities to certain medications should also be taken into consideration when choosing a medication.
  5. Potential side effects of the medication: Different medications have different side effects and some may not be suitable for certain patients. For example, older adults may be more susceptible to the side effects of certain medications and may need a lower dose or a different medication.
  6. Patient’s personal preference: Some patients may prefer a medication that can be taken orally, while others may prefer an injection or topical cream.

Overview of the Different Classes

Medication ClassExamplesPotential Side Effects
Non-Steroidal Anti-Inflammatory (NSAIDs)Ibuprofen (Motrin), Naproxen (Alieve), Diclofenac– Gastrointestinal upset / ulcers
– Kidney damage
SteroidsPrednisone, Methylprednisolone (Medrol)– Gastrointestinal upset
– Difficulty sleeping
– Difficulty controlling glucose (in diabetics)
Muscle RelaxantsCyclobenzaprine (Flexeril), Diazepam (Valium), Baclofen– Dizziness
– Drowsiness
OpioidsHydrocodone (Vicodin), Oxycodone (Percocet)– Addiction
– Nausea and vomiting
– Drowsiness
AnticonvulsantsGabapentin (Neurontin), Pregabalin (Lyrica), Carbamazepine (Tegretol)– Dizziness
– Drowsiness
AntidepressantsDuloxetine (Cymbalta), Venlafaxine (Effexor), Amitriptyline– Dizziness
– Drowsiness
Topical MedicationsLidocaine patches, Capsaicin cream– Skin irritation

A Closer Look at Each Class


How NSAIDs Work

Nonsteroidal anti-inflammatory drugs (NSAIDs) are a class of medications that are used to reduce inflammation and relieve pain. They work by blocking the production of certain chemicals in the body called prostaglandins, which are involved in the inflammation and pain response.

Examples of NSAIDs

There are many different types of NSAIDs available, both over-the-counter (OTC) and by prescription. Some examples include:

  • Aspirin
  • Ibuprofen (Advil, Motrin)
  • Naproxen (Aleve)
  • Diclofenac (Voltaren)
  • Celecoxib (Celebrex)

Side Effects of NSAIDs

While NSAIDs are generally considered safe when used as directed, they can cause side effects, some of them can be severe. Some of the most common side effects of NSAIDs include:

  • Stomach upset, such as indigestion, heartburn, and stomach ulcers.
  • Increased risk of bleeding
  • Kidney damage
  • Cardiovascular risk, particularly in people with heart disease, high blood pressure, or a history of stroke

It’s important to note that some people may be at higher risk of experiencing side effects from NSAIDs. People with a history of stomach or intestinal bleeding, or who are taking blood-thinning medications, should be particularly cautious when using these drugs.


How Steroids Work

Glucocorticoids are a type of steroid hormone that are similar to the hormone cortisol, which is produced by the adrenal glands. They are used to reduce inflammation and pain, and to suppress the immune system. Glucocorticoids are also called corticosteroids.

Examples of Steroids

Examples of glucocorticoids include:

  • Prednisone
  • Methylprednisolone (Medrol)
  • Dexamethasone (Decadron)

Glucocorticoids are often used to treat spine pain caused by inflammation and are often given in short courses, known as pulse therapy. This treatment regimen is used to help reduce inflammation and pain as quickly as possible, while minimizing the risk of side effects from long-term use.

Side Effects of Steroids

However, it’s important to note that glucocorticoids also have a number of potential side effects, including:

  • Gastrointestinal issues such as stomach pain and ulcers
  • High blood sugar
  • High blood pressure
  • Difficulty sleeping
  • Mood and behavioral changes
  • Increased risk of infection

Longer term use can cause other serious side effects such as:

  • Weight gain
  • Delayed wound healing
  • Osteoporosis and bone fractures
  • Thinning of the skin
  • Cataracts and glaucoma
  • Cushing’s Syndrome

Long-term use of glucocorticoids can also cause serious side effects, such as diabetes, cataracts, and a decrease in the body’s ability to fight infections. It’s always important to talk to your healthcare provider before taking any medication, to understand the potential benefits and risks and to ensure that it’s safe for you to use.

Muscle Relaxants

How Muscle Relaxants Work

Muscle relaxants are a class of medications that are used to relax or reduce muscle spasms and stiffness, which can help alleviate pain. They can work by different mechanisms, but some of them work by inhibiting the action of a neurotransmitter in the spinal cord, called acetylcholine, which is involved in the contraction of muscles. They are often prescribed in combination with other medications, such as pain relievers, to help manage muscle spasms or pain caused by conditions such as sprains, and strains.

Examples of Muscle Relaxants

Examples of muscle relaxants include:

  • Cyclobenzaprine (Flexeril)
  • Carisoprodol (Soma)
  • Metaxalone (Skelaxin)
  • Diazepam (Valium)
  • Baclofen (Lioresal)

Side Effects of Muscle Relaxants

Muscle relaxants can have a number of side effects, including:

  • Drowsiness and sedation
  • Dizziness and vertigo
  • Headaches
  • Nausea
  • Dry mouth
  • Blurred vision
  • Confusion

It’s important to note that these medications can cause drowsiness and impair cognitive function, so it’s recommended not to operate heavy machinery or drive while taking these medications.

Muscle relaxants should be used with caution, and only under the guidance of a healthcare provider, as they can be habit-forming, particularly if they are taken in high doses, or for long periods of time. They should be used at the lowest effective dosage for the shortest possible duration of time to minimize the risk of adverse effects.


How Opioids Work

Opioids work by binding to specific receptors in the brain and spinal cord, known as mu, delta, and kappa opioid receptors. This binding changes the way the brain and body perceive pain, and also triggers the release of other neurotransmitters, such as dopamine, which can create a sense of euphoria or well-being.

Examples of Opioids

Examples of opioids include:

  • Codeine
  • Oxycodone (OxyContin)
  • Hydrocodone (Vicodin)
  • Morphine
  • Fentanyl
  • Tramadol

Opioids are generally considered a last resort option for the treatment of back pain, as they carry a high risk of addiction and overdose. They are usually prescribed for severe pain, such as that caused by a serious injury or surgery, and are usually only used for a short period of time due to the risk of addiction and other side effects.

Side Effects of Opioids

Some of the side effects of opioids include:

  • Drowsiness and sedation
  • Nausea and vomiting
  • Constipation
  • Dizziness and confusion
  • Itchiness
  • Respiratory depression
  • Dependence and addiction

Long-term use of opioids can also cause:

  • Tolerance, which means that the patient may need higher and higher doses to achieve the same pain-relieving effect.
  • Hyperalgesia, which is a phenomenon where the patient becomes more sensitive to pain rather than less.

It’s important to note that opioids are highly addictive, and the risk of addiction and overdose increases with prolonged use. In the recent years, due to the opioid epidemic, the medical community is more cautious in prescribing opioids.


How Anticonvulsants Work for Pain

Anticonvulsants, also known as antiepileptic drugs, are a class of medications that are primarily used to treat seizures in people with epilepsy. They work by stabilizing the electrical activity in the brain and preventing seizures. However, some of these drugs have also been found to be effective in managing certain types of chronic pain, such as neuropathic pain, which is caused by damage or dysfunction of the nervous system.

Anticonvulsants are thought to work for chronic pain by stabilizing abnormal electrical activity in the nerves, which can reduce pain signals being sent to the brain. Some of them also work by modifying the activity of neurotransmitters, the chemical messengers in the brain that are involved in pain perception.

Examples of Anticonvulsants

Examples of anticonvulsants that are used to treat chronic pain include:

  • Gabapentin (Neurontin)
  • Pregabalin (Lyrica)
  • Carbamazepine (Tegretol)
  • Lamotrigine (Lamictal)
  • Topiramate (Topamax)

Anticonvulsants are commonly used to manage chronic back pain caused by conditions such as radiculopathy, postherpetic neuralgia, and spinal cord injury. They are also sometimes used to help manage chronic pain caused by fibromyalgia, diabetic neuropathy, and other conditions.

Side Effects of Anticonvulsants

Like any medication, anticonvulsants also have side effects, some of them include:

  • Drowsiness and sedation
  • Dizziness
  • Nausea and vomiting
  • Diarrhea or constipation
  • Headache
  • Tremors


How Antidepressants Work for Pain

Antidepressants are a class of medications that are primarily used to treat depression, but some of them have also been found to be effective in managing certain types of chronic pain, such as neuropathic pain, and chronic back pain. They work by altering the levels of certain neurotransmitters, such as serotonin and norepinephrine, in the brain. These neurotransmitters play a role in regulating mood, pain, and other bodily functions.

Examples of antidepressants that are used to treat chronic pain include:

  • Tricyclic antidepressants (TCAs) such as amitriptyline (Elavil) and nortriptyline (Pamelor)
  • Selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine (Prozac) and duloxetine (Cymbalta)

Antidepressants are thought to work for chronic pain by modulating the activity of neurotransmitters, which can reduce pain signals being sent to the brain. Some antidepressants are believed to help reduce chronic pain by decreasing the amount of substance P, a chemical in the body that is involved in pain perception.

Antidepressants can take several weeks to start working, and are generally used as a part of a multidisciplinary treatment plan for chronic pain that may include physical therapy, psychological support, and other medications.

Side Effects

Some side effects include:

  • Nausea
  • Drowsiness
  • Insomnia
  • Constipation
  • Sexual dysfunction
  • Weight gain
  • Dry mouth

It’s also important to keep in mind that antidepressants can take several weeks to start working, and it may take some time to find the right medication and dosage.

Topical Medications

Topical treatments for back pain refer to medications or other substances that are applied directly to the skin over the affected area. These treatments are intended to deliver relief by providing a concentrated dose of medication to the affected area without exposing the entire body to the drug.

Examples of topical treatments for back pain include:

  • Creams, gels, or ointments containing nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen or diclofenac. These work by reducing inflammation and pain.
  • Capsaicin cream, made from a compound found in chili peppers. It works by reducing the amount of a substance called substance P, which sends pain signals to the brain.
  • Topical lidocaine patch, a local anesthetic, which can provide temporary relief of pain and discomfort
  • Topical methyl salicylate, a mild pain reliever, which can be found in muscle rubs, and can help with pain, stiffness and muscle soreness.

Topical treatments for back pain are often considered to be a safer alternative to oral medications, as they can provide targeted relief to the affected area and have fewer systemic side effects. However, they may still cause some local side effects, such as skin irritation, redness

Discuss with your Doctor

There are several classes of medications that can be used to treat spine pain, each with their own unique mechanism of action and indications. Ultimately, the choice of medication will depend on the specific circumstances of the patient, and it is important that the treatment plan is tailored to the individual’s needs and is guided by a healthcare professional.

About the Author

Dave Harrison, MD

Dr. Harrison is a board certified Emergency Physician with a part time appointment at San Francisco General Medical Center and is an Assistant Clinical Professor-Volunteer at the UCSF School of Medicine. Dr. Harrison attended medical school at Tufts University and completed his Emergency Medicine residency at the University of Southern California. Dr. Harrison manages the editorial process for