Medication for back pain.
What works and what doesn't.
Medication plays a modest role in the treatment of back pain. No medication cures back pain; they can only temporarily relieve the symptoms. Below is an overview based on the latest guidelines.
Paracetamol
Guidelines disagreeEvidence
The PACE trial (Lancet, 2014) showed that paracetamol does not work better than placebo for acute low back pain, confirmed by Cochrane (2016). The WHO (2023) and NICE therefore do not recommend it. The Dutch GP guideline does keep it as step one, in the stepladder of the NHG standard on pain: Thuisarts.nl advises “start with paracetamol, it has the fewest side effects”, because no painkiller works particularly well here and this one does the least harm.
Dosage
If you use it: follow the packaging, and judge after a few days whether it actually helps you.
Side effects
Few side effects with normal use, but liver toxicity with overdose.
NSAIDs (ibuprofen, naproxen, diclofenac)
Moderately effectiveEvidence
NSAIDs have the best evidence of all painkillers for acute low back pain (WHO 2023, NICE 2016, Cochrane 2020), and in a review of 301 placebo-controlled trials they were the only treatment shown to work for acute back pain (Cashin et al., 2025). The effect is small, and across all analgesics the uncertainty is considerable (Wewege et al., BMJ 2023).
Dosage
Ibuprofen 400mg max 3x/day, naproxen 250-500mg max 2x/day. Maximum 7-14 days. Take with food.
Side effects
Stomach complaints, stomach bleeding with long-term use. Caution with kidney disease, heart failure, high blood pressure. Do not combine with blood thinners. Do not use during pregnancy, especially not in the third trimester.
Opioids (tramadol, codeine, oxycodone)
Not recommendedEvidence
The WHO (2023) does not recommend opioids for low back pain. The OPAL trial (Lancet, 2023) showed that opioids do not work better than placebo for acute low back pain, with more side effects. The risk of dependence, misuse, and overdose is significant.
Dosage
Only on prescription, as briefly as possible, lowest dose.
Side effects
Drowsiness, nausea, constipation, dizziness, respiratory depression, addiction risk. Tolerance build-up with long-term use.
Muscle relaxants (diazepam, tizanidine)
Limited evidenceEvidence
There is limited evidence that muscle relaxants provide short-term pain relief in acute back pain with muscle spasm. The effects are small and the side effects (especially drowsiness) are significant. Not recommended for long-term use. NICE and WHO are cautious.
Dosage
Only on prescription. Short-term (max 1-2 weeks). Do not combine with alcohol.
Side effects
Drowsiness, dizziness, muscle weakness, dependence risk (benzodiazepines). Do not drive.
Antidepressants (duloxetine, amitriptyline)
Some evidenceEvidence
Duloxetine (SNRI) has some evidence for effectiveness in chronic low back pain (ACP 2017). The NNT is around 7-8. Amitriptyline (TCA) is sometimes used for neuropathic pain, but the evidence for back pain is limited. Not suitable for acute back pain.
Dosage
Duloxetine 60mg/day. Amitriptyline 10-25mg at night. Build up over weeks.
Side effects
Nausea, dry mouth, drowsiness, weight gain, sexual side effects. Taper off gradually.
Key message
No painkiller works particularly well for back pain. NSAIDs have the best evidence for acute back pain and can be used short-term; paracetamol did not beat placebo in trials, but your GP still starts there because it carries the least risk. Opioids are not recommended. Whatever you take, combine it with movement and staying active, and ask your GP or pharmacist what fits your situation.
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