First-Line Medication for Radiculopathy

Initial Pharmacological Approach

The American College of Physicians recommends NSAIDs as initial treatment for chronic low back pain with moderate short-term efficacy 1
NSAIDs like naproxen should be initiated first due to moderate efficacy and better safety profile compared to other options 2
NSAIDs primarily target the inflammatory component of radicular pain 1
The American Academy of Neurology suggests gabapentin may provide benefits in pain alleviation and improved quality of life in chronic radiculopathy 2
Gabapentin shows small to moderate short-term benefits specifically for radicular pain and should be added to NSAIDs for the neuropathic component 1, 2

Start with naproxen at the lowest effective dose 2
Add gabapentin if pain persists, starting low and titrating gradually (especially in older patients) 2
For acute exacerbations with severe muscle spasm, consider adding cyclobenzaprine for short-term use (≤1-2 weeks only) 1
If insufficient response, consider adding tricyclic antidepressants (amitriptyline) or duloxetine 1

Do NOT use systemic corticosteroids - they are ineffective compared to placebo for radiculopathy 1, 3
Avoid benzodiazepines - ineffective for radiculopathy based on low-quality evidence 1
Pregabalin shows no benefit for chronic nonradicular back pain and may worsen function 1
Muscle relaxants should never be used beyond 1-2 weeks - no evidence supports efficacy beyond this timeframe 1

For pregnant patients with radiculopathy, amitriptyline, duloxetine, and venlafaxine are considered safe 3
Gabapentin is not mentioned as safe in pregnancy despite being first-line in non-pregnant patients 3
Avoid muscle relaxants and systemic corticosteroids during pregnancy 3