Although pain relievers, muscle relaxants, and antidepressants are commonly used for neck pain, none are well-proven treatments.

Nonprescription pain relievers include:

• Creams or gels, such as Bengay, that are rubbed into the neck.
• Acetaminophen, such as Tylenol, which reduces pain.
• Nonsteroidal anti-inflammatory drugs, including aspirin (such as Bayer), ibuprofen (such as Advil), or naproxen sodium (such as Aleve), that can help relieve pain and reduce inflammation. Do not give aspirin to anyone younger than 20 because of the risk of Reye syndrome.

Prescription pain relievers include:

• Muscle relaxants, which are used to treat severe neck pain and spasms when neck pain begins (acute neck pain). They include diazepam (such as Valium), cyclobenzaprine (such as Flexeril), and carisoprodol (such as Soma).
• Narcotic pain relievers, which are used to treat severe short-term (acute) neck pain. They include codeine, acetaminophen and hydrocodone (such as Vicodin, Lortab), aspirin and oxycodone (such as Percodan), and acetaminophen and oxycodone (such as Percocet).
• Antidepressants, which are used to treat long-lasting (chronic) pain. They include doxepin (such as Sinequan) and amitriptyline (such as Elavil).

1. Muscle and Bone (Nociceptive) Pain: In general, the categories of medications used to treat nociceptive back and neck pain include:

• Non-steroidal anti-inflammatory drugs (NSAIDs)
• Narcotic medications or opioids
• Tranquilizing medications
• Anticonvulsant medication or antiepileptic medication
• Steroidal anti-inflammatory medication

a. Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)

Traditionally, NSAIDs are used to treat muscle and bone pain. Many of these drugs are household terms, such as ibuprofen (Advil) and naproxen (Aleve). Others are newer and more expensive, such as COX-2 inhibitors: celecoxib (Celebrex). As a group, these agents are widely prescribed.

While NSAIDs are widely prescribed and effective in reducing acute pain and inflammation, they have significant side effects, especially taken for long periods of time. The most common side effects of NSAIDs are gastrointestinal bleeding, bleeding disorder (but not related to taking COX-2 inhibitors), hypertension and fluid retention. Although all of the NSAIDs can cause stroke or heart attack, they rarely do so. Used long-term or with other medications, some NSAIDs also have been associated with liver problems.

b. Narcotic or Opioid Medications

The most widely used prescription pain drugs are commonly known as "narcotics." The term narcotic is an old Greek word meaning "sleep." The preferred modern term for these medications is "opioids." Opioids act on the brain relay systems for the normal processing of pain. Commonly prescribed opioid pain medications include:

• codeine (Tylenol #3)
• hydrocodone (Vicodin, Lorcet, Zydone, Norco)
• oxycodone (Percocet, Oxy IR, Roxicodone, or Oxycontin)
• morphine ( Avinza, MS Contin, Oramorph or Kadian)
• fentanyl (Duragesic or Actique)
• methadone (methadone or methadose)

c. Muscle Relaxants

Some pain medications act more by relaxing muscles than as direct central nervous system pain relievers. Commonly prescribed muscle relaxants include:

• carisoprodol (Soma)
• diazepam (Valium)
• methocarbamol (Robaxin)
• tizanidine (Zanaflex)
• cyclobenzaprine (Flexeril) The US Food and Drug Administration (FDA) does not recommend the long-term use of muscle relaxants because they no longer are effective in actual muscle relaxation after two weeks of use. Soma or carisoprodol is metabolized to the sedative meprobamate in the body and can be habit forming.

Some drugs such as acetaminophen (Tylenol) and paracetamol (a popular European acetaminophen-like medication) are thought to provide pain relief via central brain mechanisms.

2. Nerve Pain (Neuropathic)

The treatment for nerve pain focuses on the use of medications that are not normally labeled as pain relievers, but because of their properties they may help the body fight the pain. These medications are called "adjuvant" medications or "membrane stabilizers."

These medications help the body reprogram the messages involved in relaying the pain signals and include:

• tricyclic and herocyclic antidepressants (Elavil, Nortryptalline, Desipramine, etc.)
• anticonvulsants (Neurontin, Lyrica, Keppra, Topomax, Dilantin, etc.)
• selective serotonin reuptake inhibitors (SSRI) antidepressants (Prozac, Paxil, Lexapro, Zoloft, etc.)
• selective norepinephrine reuptake inhibitors (SNRI) antidepressants (Effexor, Cymbalta)
• others such as beta blockers, alpha blockers, benzodiazepenes, etc.

Nerve pain is sub-classified as peripheral nerve pain, central nerve pain, and, by some pain authorities, as sympathetically mediated nerve pain, or pain involving the autonomic nervous system. There are specific "transmitters" for each of the nerve pathways that transmit messages from one nerve to another ¨C these are called "neurotransmitters."

Determining if nerve pain is central or peripheral and then "inhibiting or accentuating" the pain signals requires knowledge and experience on the part of your physician.

The following table lists some of the neuropeptides and neurotransmitters involved in relaying pain messages.

Neuropeptides
Neurotransmitters
Glutamate (Primary Neuron)
Serotonin
Substance P (Primary Neuron)
Noradrenalin
NMDA (N-methyl-d-aspartate) (2o Neuron)
Dopamine
AMPA (2o Neuron)
GABA
Endorphins - Beta, encephalin, dynorphins
Acetylcholine
Neurotransmitter Therapy

We know that the neurotransmitters serotonin, noradrenalin, NMDA, Substance P, Glutamate and GABA are center stage players in increasing or decreasing nerve pain. It is vitally important to become familiar with the medications and/or nutritional supplements that augment the levels or increase the flow of these hormone messengers. Serotonin has become a household word because of its known effect on depression and its crucial role in treating migraine headaches. Serotonin may activate the central "gate" into the higher nervous system, including the brain, so that incoming signals from below the brain have more difficulty entering your consciousness. This is called increasing descending inhibition, or "raising the wall."

Medications that can raise serotonin include:

• Nutritional substances L-tryptophane, or 5-hydroxy-tryptophane
• Prescription medications such as: fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), ecitalopram (Lexapro).

Medications with noradrenaline activity also are effective in treating nerve or neuropathic pain conditions. Animal and human research suggests that medications with both noradrenaline and serotonin activity are the most effective of these drugs for neuropathic pain. Thus medications typically prescribed for nerve-related back or neck pain that radiates into the arms or legs include: duloxetene (Cymbalta), venlafaxine (Effexor), amitriptylene (Elavil), imipramine (Tofranil), desipramine (Norpramine), nortriptylene (Pamelor), and doxepin (Sinequan).

In other cases, raising central dopamine levels can relieve nerve pain and restore musculoskeletal movements. Medications that raise this neurotransmitter's level include amoxapine (Ascendin).

3. Nerve Blocking Medications

When nerve pain comes from an irritated nerve outside the spinal cord, there are two primary ways to block the pain. A physician must either block the peripheral nerve with local anesthetics or directly block the substances P and glutamate in the primary neuron.

• Local anesthetics include novocaine, lidocaine, bupivacaine, ropivacaine or chirocaine.
• Primary neuron blocks include over-the-counter pepper creams and high-potency pepper cream, capsaicin (Zostrix), which depletes the neuron of substance P. Glutamate in the primary neuron can be partially blocked with gabapentin (Neurontin) or with glycine.

Treatment for pain related to secondary neurons¡ªthose next to the spinal cord¡ªincludes methadone (Dolophine), dextromethorphan, ketamine and amantadine.

For pain related to tertiary neurons ¡ª those in the brain ¡ª central acting agents work best. They include: gabapentin (Neurontin), topiramate (Topamax), tiagabine (Gabitril), phenytoin (Dilantin), valproic acid (Depakote), lamotragine (Lamictal) and carbamazapine (Tegretol).

4. Steroid Medications

Steroid medications are potent anti-inflammatory hormones that can be useful in easing pain and acute flare-ups in inflammation. Such medications include: methylprednisolone (Medrol), dexamethasone (Decadron), and prednisolone (Prednisone).

Comments: Steroid medications must be used with extreme caution, especially if they are used for longer than a short-time period (up to a week). Steroids can suppress the body's output of normal cortisone through the adrenal glands, inhibit the effectiveness of the white blood cells which fight off infection, cause fluid retention and swelling, and cause increased appetite and weight gain.

In terms of low back problems, steroids can cause bony resorption and osteoporosis. In diabetics, steroids can increase blood sugar. Because of these many complications, careful follow up is essential when using these medications

5. Botulinum toxin type A (Botox)

Botulinum toxin type A has been approved by the US Food and Drug Administration for the injection treatment of muscle spasm. Often used for painful muscle spasms all over the body, botulinum toxin type A takes about three to 10 days before the patient experiences relief. The effects of the medication last for three to four months. Patients may experience some side effects, including excessive paralysis or difficulty swallowing, but these are self-limiting. Patients may develop tolerance to botulinum toxin type A. When this occurs, botulinum toxin type B often can be helpful.

6. Botulinum toxin type B (Myobloc)

Botulinum toxin type B has been approved by the US Food and Drug Administration for treatment of cervical dystonia to reduce the severity of abnormal head position and neck pain. Cervical dystonia is a neurological movement disorder characterized by involuntary muscle contractions, which force the neck into abnormal, sometimes painful, movements or postures.

Botulinum toxin type B works by blocking the nerve impulses that control muscle movement. Botulinum toxin type B temporarily paralyzes the muscles, which prevents the involuntary muscle contractions associated with cervical dystonia. Although controlled studies remain to be done, anecdotal reports (case series, open label trials, etc) of response to botulinum toxin type B have been reported for pain management related to muscle stiffness, chronic lower back pain, movement disorders, and muscle spasticity related to stroke and multiple sclerosis, indicating that in individual cases, botulinum toxin type B may be helpful.