NICE’s Clinical Knowledge Series on sciatica indicates that oral NSAIDs such as ibuprofen or naproxen (with a gastroprotective agent) are first line options if appropriate for the patient.11

If an NSAID is not suitable or effective, codeine with or without paracetamol may be considered, but the potential for constipation should be taken into account, as straining to defecate may aggravate sciatica. Paracetamol should not be offered on its own for sciatica.

If sciatica pain is uncontrolled, then a drug to treat neuropathic pain may be necessary following the NICE guideline on neuropathic pain in adults. This means amitriptyline, duloxetine, gabapentin or pregabalin could be considered as initial treatment. Dosing should be titrated according to response and tolerability and follow local prescribing policies. If the patient does not respond to whichever drug is tried first, then each of the other drugs could be tried.11,15,20

The neuropathic pain guidelines also indicate topical capsaicin cream may help if the pain is considered localised. This may offer an option for patients wishing to avoid or who cannot take oral treatments.20

Tramadol should only be tried for neuropathic pain if acute rescue therapy is needed, and it should not be used in the long term.20

If symptoms persist or worsen over two weeks the patient should return to the prescriber for further consideration.11