Pharmacological management for acute nonspecific neck pain

Ensure nonpharmacological treatments for acute nonspecific neck pain have been considered (particularly reassurance) before implementing pharmacological management (see Management approach for acute nonspecific neck pain for more detail).

Explain to the patient that the goal of pharmacological management is to reduce, rather than abolish, pain so that physical function can be maintained. Oral analgesia can be useful to facilitate exercise and staying active. Some pain on activity is likely, but this does not imply damage to the spine.

Note: The goal of pharmacological management is to reduce, rather than abolish, pain so physical function can be maintained.

All of the nonsteroidal anti-inflammatory drugs (NSAIDs) listed below are equally effective and drug choice should be based on patient factors (eg comorbidities); see Choosing an NSAID for advice on drug choice. A trial of an NSAID is recommended for short-term pain relief, use:

1celecoxib 100 to 200 mg orally, daily in 1 or 2 divided doses, until symptoms subside celecoxib celecoxib celecoxib

OR

1etoricoxib 30 to 60 mg orally, daily until symptoms subside etoricoxib etoricoxib etoricoxib

OR

1ibuprofen immediate-release 200 to 400 mg orally, 3 or 4 times daily until symptoms subside ibuprofen ibuprofen ibuprofen

OR

1indometacin 25 to 50 mg orally, 2 to 4 times daily until symptoms subside indometacin indometacin indometacin

OR

1ketoprofen modified-release 200 mg orally, daily until symptoms subside ketoprofen ketoprofen ketoprofen

OR

1meloxicam 7.5 to 15 mg orally, daily until symptoms subside meloxicam meloxicam meloxicam

OR

1naproxen immediate-release 250 to 500 mg orally, twice daily until symptoms subside naproxen naproxen naproxen

OR

1naproxen modified-release 750 to 1000 mg orally, daily until symptoms subside naproxen naproxen naproxen

OR

1piroxicam 10 to 20 mg orally, daily until symptoms subside piroxicam piroxicam piroxicam

OR

2diclofenac 25 to 50 mg orally, 2 or 3 times daily until symptoms subside. diclofenac diclofenac diclofenac

The efficacy of paracetamol in neck pain has not been studied in clinical trials. However, if NSAIDs are contraindicated or not tolerated, consider using paracetamol because of its favourable safety profile. Use:

1paracetamol immediate-release 1 g orally, 4- to 6-hourly as necessary, up to a maximum of 4 g daily paracetamol paracetamol paracetamol

OR

1paracetamol modified-release 1.33 g orally, 8-hourly as necessary. paracetamol paracetamol paracetamol

For patients with pain that persists throughout the day, or if there is inadequate response to ‘as necessary’ dosing, consider a trial of regular rather than ‘as necessary’ dosing of oral analgesia.

A recent clinical trial found tricyclic antidepressants (TCAs) may have a role in neck pain in the intermediate term. A trial of a low-dose TCA may be considered if pain is not adequately relieved with other measures and is persisting beyond 2 to 3 weeks. TCAs may be particularly useful if pain is interfering with sleep. An example regimen is:

amitriptyline 10 to 25 mg orally, in the early evening; increasing the daily dose by up to 25 mg every 2 to 4 weeks as tolerated and according to response, up to a maximum maintenance dose of 50 mg each evening. amitriptyline amitriptyline amitriptyline

To reduce the risk of daytime drowsiness, start at a low dose and increase it slowly as tolerated. If drowsiness during the day is a concern, nortriptyline and doxepin may be preferred. TCAs should be used with care in older patients and in patients with cardiovascular disease.

Opioids are not recommended for the management of acute nonspecific neck pain. The efficacy of opioids in neck pain has not been studied in clinical trials and they are associated with a significant risk of harms.

Muscle relaxants (eg diazepam) are not recommended for acute nonspecific neck pain because there is limited evidence to support their use, and their potential harms may outweigh any potential benefits. Drowsiness, dizziness, increased risk of falls and dependency are common adverse effects.