The Medicine Cabinet: Ask the Harvard Experts
By Howard LeWine, M.D.
Q: I have been struggling with a persistent pain on the right side of my belly. Sometimes it feels like it moves from the back to the front and back again. My doctor first ordered blood tests and an abdominal ultrasound. Most recently I had a CT scan of my belly. All normal! My doctor now thinks it might be a pinched nerve. Can a pinched nerve cause this much pain?
A: What you describe is actually quite common. Yes, it does sound like your pain is coming from an irritated nerve leaving the spine. These spinal nerves wrap around from the center of your back to the sides of your body. Doctors call this type of nerve pain radiculopathy, or spinal nerve root pain.
Indeed, the pain can be very severe. Both the patient and the doctor often get concerned that the pain could be related to an intra-abdominal problem. So, it’s not surprising that you had the blood tests, ultrasound and CT scan.
Treating persistent nerve pain can be frustrating. Nerve pain often has a very irritating quality that can be more uncomfortable than pain due to other causes.
There is no single best approach. Finding the right therapies and medications to control persistent pain is a process of trial and error. The goal is to find the most effective combination with the least amount of side effects, while trying to keep costs reasonable.
I often suggest a combination of a nonsteroidal anti-inflammatory drug (NSAID) and one of the tricyclic antidepressants. These are available as inexpensive generics. If you cannot take NSAIDs because of an allergy, kidney problems, gastritis, or peptic ulcer disease, acetaminophen can also be combined with a tricyclic.
Of the NSAIDs, naproxen tends to be my first choice for chronic pain because you only need to take it twice per day. Ibuprofen is just as effective. And if one doesn’t work, try the other.
When I prescribe a tricyclic antidepressant for pain, patients often respond, “But I am not depressed.” Today, tricyclics are used more for treatment of chronic pain, especially persistent nerve pain. Examples include amitriptyline, nortriptyline, desipramine, and doxepin.
I recommend starting with a very low dose, such as 10 milligrams of amitriptyline at night. These drugs can be very sedating; increase the dose gradually. Unlike NSAIDs and acetaminophen, you won’t get the pain relief right away from the tricyclic. It may take a few weeks to work.
There are many other medications available to help relieve nerve pain, including agents applied directly to the skin. Be patient. It may take you and your doctor a while to find a good strategy to ease your symptoms.
(Howard LeWine, M.D. is an internist at Brigham and Women’s Hospital in Boston and assistant professor of medicine at Harvard Medical School. For additional consumer health information, please visit www.health.harvard.edu.)