Anti-inflammatory pain relievers (NSAIDs)

NSAID stands for nonsteroidal anti-inflammatory drug. These medicines ease pain, inflammation and fever, and they are not steroids. They are among the most common medicines people take for back and neck pain.

Over the counter

Ibuprofen (Advil, Motrin), naproxen (Aleve) and aspirin are sold without a prescription. Over-the-counter versions come in lower strengths, and their labels are written for short-term use without a clinician’s advice.

Many people take a daily low dose of aspirin to protect the heart. That is a different use, and it should not be stopped without talking with your clinician.

Prescription

Clinicians can prescribe higher strengths of ibuprofen and naproxen, or other NSAIDs such as meloxicam (Mobic), diclofenac and celecoxib (Celebrex). Celecoxib belongs to a group called COX-2 inhibitors, which were designed to be gentler on the stomach.

NSAIDs also come as gels and patches that go on the skin. This page covers NSAIDs taken by mouth.

When tissue is irritated or injured, the body makes chemical messengers called prostaglandins. They drive inflammation and make nerves more sensitive to pain.

NSAIDs block the COX enzymes that make prostaglandins. Less prostaglandin means less inflammation and pain.

Prostaglandins and related chemicals also protect the stomach lining, keep blood flowing to the kidneys, and help control blood clotting. Blocking them explains most NSAID side effects.

NSAIDs do not fix the cause of back or neck pain. The hope is to ease pain enough to keep moving while it settles.

Before you start

Your clinician or pharmacist will want to know about any past stomach ulcers or bleeding, kidney or liver disease, heart disease, heart failure or stroke, a recent or planned heart bypass surgery, high blood pressure, asthma, and pregnancy.

Also mention all your medicines, especially blood thinners, steroid pills, antidepressants such as SSRIs or SNRIs (including duloxetine), lithium, methotrexate, blood pressure pills, water pills (diuretics) and daily aspirin.

While you take it

The usual rule is the lowest dose that helps, for the shortest time needed. Follow the label or your prescriber’s directions.

Taking two NSAIDs at once, such as ibuprofen with naproxen, raises the risk of stomach bleeding. Some combination products, such as certain cold medicines, also contain an NSAID, so check labels. An NSAID gel on the skin adds a smaller amount, so mention it to your clinician too.

If you take low-dose aspirin for your heart, ibuprofen can block part of aspirin’s protective effect. Ask your clinician or pharmacist about timing, or whether another pain reliever makes more sense.

Checking in

Check in with your clinician if you are taking an NSAID on most days, or if your pain is not improving.

For new (acute) low back pain, NSAIDs work slightly better than a placebo (a dummy pill) in the first few weeks. The extra relief is small. The review authors judged it probably too small to matter for many people. [1]

Averages hide a range. Some people have a meaningful drop in pain that others do not.

For long-lasting (chronic) low back pain, NSAIDs also help slightly more than a placebo, but the benefit is small and the evidence is weaker. [2]

For sciatica, meaning pain down the leg from an irritated nerve, studies have not shown clear pain relief compared with a placebo. [7]

For neck pain there is much less research, though what exists suggests NSAIDs may help somewhat more than a placebo. Different NSAIDs, including celecoxib, seem to work about equally well for back pain. [8] [23] [24]

The American College of Physicians’ 2017 guideline suggests starting with non-drug care such as heat or exercise. If medicine is wanted, it lists NSAIDs among the first choices. [15]

Most new episodes of low back pain improve a lot within about 6 weeks, with or without medicine. [25]

Most people who take an NSAID for a short time have no serious problems. Risks rise with higher doses, longer use, older age, and some health conditions.

Common

• Upset stomach, heartburn or nausea.

Less common

• Higher blood pressure, and blood pressure medicines working less well.
• Holding on to fluid, which can cause swollen ankles.
• Wheezing or worse asthma. Some people with asthma react to aspirin, and many of them also react to other NSAIDs such as ibuprofen and naproxen.

Less common but serious

• Stomach ulcers and bleeding, which can happen without warning signs. Each year, a small share of people who take NSAIDs regularly has a serious stomach problem such as bleeding. The risk is higher with older age, a past ulcer, blood thinners, steroid pills, heavy drinking, higher doses, or more than one NSAID.

Rare but serious

• Heart attack and stroke. In 2015 the US Food and Drug Administration strengthened its warning that non-aspirin NSAIDs raise this risk, which can start in the first weeks of use.
• The added risk for any one person is small, but it is higher with higher doses and in people who already have heart disease or its risk factors.
• Worsening heart failure, because NSAIDs make the body hold on to salt and water.
• Sudden kidney injury, most often in people who are dehydrated, have kidney disease, are older, or take a water pill together with certain blood pressure medicines.
• Serious allergic reactions, such as hives, face swelling or trouble breathing.
• Very rarely, NSAIDs cause a severe skin reaction. Stop taking the NSAID and get medical help right away for a new rash, blisters, or peeling skin.

Celecoxib

Celecoxib causes fewer stomach problems than ibuprofen or naproxen, but it is not free of stomach risk, and it still carries heart and kidney risks. Its label warns against it (opens in a new tab) for people who have had an allergic reaction to sulfa medicines.

Pregnancy and older age

• The FDA advises avoiding NSAIDs from about 20 weeks of pregnancy onward unless a clinician recommends one. They can affect the baby’s kidneys and lower the fluid around the baby. This does not apply to low-dose aspirin that a clinician has prescribed during pregnancy. Do not stop it without talking with your clinician.
• Ask your clinician before taking an NSAID at any stage of pregnancy.
• Adults over 65 are more likely to have stomach bleeding and kidney problems. Guidance for older adults advises against long-term regular use in most cases.

Other downsides

• Relief is modest and short term, and back or neck pain often comes back.

Get emergency care for chest pain, trouble breathing, swelling of the face, lips or throat, weakness on one side of the body, slurred speech, vomiting blood, or black or bloody stools. Stop the NSAID and call your clinician for stomach pain that does not go away, new swelling in your legs, or passing much less urine than usual.