Management of common acute pain conditions in the outpatient clinic: a guide to the general practitioner

ABSTRACT

BACKGROUND AND OBJECTIVES  Acute pain serves a critical role in warning and recovery processes of tissue injury, but may transition into chronic pain, especially if inadequately treated, resulting in profound long-term quality-of-life impairments and increased healthcare costs. Effective management of acute pain mitigates the risk of chronicity by disrupting the neuroplastic changes associated with pain sensitization. This paper reviews the current evidence and provides recommendations from a panel of pain medicine specialists for general practitioners regarding the management of common acute pain conditions in the outpatient setting: acute musculoskeletal pain, acute low back pain, herpes zoster, migraine and tension-type headache attacks. It also discusses the particularities of addressing acute pain among special populations, such as children, the elderly and pregnant women.

CONTENTS  Opioids retain an important role in addressing acute pain due to their rapid and effective relief across nociceptive, neuropathic, and mixed pain types. However, their use requires caution due to short-term side effects, tolerance issues, and the risk of addiction in long-term scenarios. Multimodal analgesia, integrating pharmacological and non-pharmacological approaches, represents a pivotal shift in pain management strategies.

CONCLUSION  General practitioners are encouraged to adopt individualized, multimodal approaches, balancing efficacy with safety, to improve functionality and patient outcomes in managing acute pain. These recommendations aim to equip frontline physicians with practical tools to address this complex condition effectively and reduce its long-term consequences.

Keywords:
Acute pain; Headache; Low back pain; Opioid analgesics; Neuralgia

HIGHLIGHTS

Effective acute pain management prevents chronicity by interrupting neuroplastic changes linked to pain sensitization.

Opioids provide rapid relief for acute pain but require careful dosing due to risks of tolerance, side effects, and addiction in long-term use

Multimodal analgesia, combining pharmacological and non-pharmacological methods, improves pain outcomes and reduces opioid reliance

Non-pharmacological therapies, such as manual therapy and physical exercises, are essential in acute musculoskeletal and low back pain management

Special considerations apply to pain management in elderly, children, and pregnant individuals due to varied physiological and pharmacological challenges

RESUMO

JUSTIFICATIVA E OBJETIVOS  A dor aguda desempenha um papel crítico nos processos de alerta e recuperação de lesões teciduais, mas pode evoluir para dor crônica se não for tratada de forma adequada, resultando em consequências negativas à qualidade de vida a longo prazo, e em custos elevados para os sistemas de saúde. O manejo eficaz da dor aguda reduz o risco de cronificação ao mitigar a ocorrência de alterações neuroplásticas associadas à sensibilização da dor. O objetivo deste estudo foi revisar as evidências disponíveis e apresentar recomendações de um painel de especialistas em medicina da dor para médicos generalistas sobre o manejo de condições comuns de dor aguda no contexto ambulatorial, incluindo: dor musculoesquelética, lombalgia aguda, herpes-zóster, enxaqueca e cefaleia tipo-tensão. Ele também discute as particularidades do manejo da dor em populações específicas, como crianças, idosos e gestantes.

CONTEÚDO  Opioides continuam a desempenhar um papel importante no alívio rápido e eficaz da dor nociceptiva, neuropática e mista, mas seu uso exige cautela devido a efeitos adversos a curto prazo, bem como problemas de tolerância e risco de dependência quando do uso prolongado. A analgesia multimodal, que integra abordagens farmacológicas e não farmacológicas, representa uma mudança significativa no paradigma atual de manejo da dor.

CONCLUSÃO  Os clínicos são incentivados a adotar abordagens individualizadas e multimodais, equilibrando eficácia e segurança, para promover a funcionalidade e obter desfechos clínicos satisfatórios no manejo da dor aguda. Estas recomendações visam equipar médicos generalistas com ferramentas práticas para abordar esta condição complexa e reduzir suas consequências a longo prazo.

Descritores:
Analgésicos opioides; Cefaleia; Dor aguda; Dor lombar; Neuralgia

DESTAQUES

O tratamento eficaz da dor aguda previne a cronicidade ao interromper as alterações neuroplásticas ligadas à sensibilização à dor

Opioides proporcionam rápido alívio para a dor aguda, mas exigem uma dosagem cuidadosa devido aos riscos de tolerância, efeitos adversos e dependência no uso prolongado

A analgesia multimodal, que combina métodos farmacológicos e não farmacológicos, melhora os resultados da dor e reduz a dependência a opioides

As terapias não farmacológicas, como terapia manual e exercícios físicos, são essenciais no controle da dor musculoesquelética e lombar aguda

Considerações especiais se aplicam ao controle da dor em idosos, crianças e gestantes devido a variados desafios fisiológicos e farmacológicos

INTRODUCTION

Acute pain, a warning signal resulting from injuries or diseases, plays a fundamental role in protection and recovery of the human organism¹ . However, when not adequately treated, this type of pain can evolve into chronic pain, a debilitating condition that affects millions of people worldwide² . The transition from acute to chronic pain is not a linear process but a complex phenomenon influenced by various factors, including pain severity and duration³ , psychological and genetic factors¹ and effectiveness of acute pain management. In fact, lack of adequate treatment for acute pain can lead to neuroplastic changes that perpetuate pain, even after the resolution of the initial injury⁴ . Treating acute pain not only alleviates immediate suffering but also plays a crucial role in preventing chronic pain. By interrupting the chain of events that lead to pain sensitization and chronicity, early and effective treatment of acute pain can improve quality-of-life, reduce long-term drug use, and reduce healthcare costs⁵ .

This expert-led literature review on acute pain management highlights the crucial role early treatment plays in preventing chronic pain. Research indicates that untreated or poorly managed acute pain often leads to maladaptive neural changes, resulting in pain sensitization and chronicity. By prioritizing effective acute pain management, healthcare professionals can mitigate these risks, thereby preserving patients' quality of life, reducing dependence on long-term analgesics, and alleviating the economic burden on healthcare systems. These findings justify further investigation of targeted therapies for acute pain as a strategic approach to curbing the global chronic pain epidemic. This article presents the main pharmaceuticals for outpatient acute analgesia, discusses the role of opioids in this context, and explores multimodal analgesia, translating evidence from the operative to the outpatient setting. It addresses acute musculoskeletal pain, acute low back pain with and without sciatica, acute Herpes Zoster, and type-tension headache and migraine attacks, in addition to discussing the treatment of pain in special populations such as the elderly, children and adolescents, and pregnant and breastfeeding women

CONTENTS

Main drugs for outpatient acute analgesia

The most important drugs recommended for acute analgesia available in Brazil are presented in Table 1.

Table 1
Main drugs recommended for acute analgesia available in Brazil.

Drugs	Available presentations	Recommended doses and posology	Most common adverse events	Observations
Dypirone	Tablets 500 and 1000mg	500-1000 mg every 4-6h	Injectable dipyrone can cause transient hypotension; Allergic reactions; bone marrow aplasia (rare)	Avoid high doses in patients with severe renal and/or hepatic insufficiency.
		(500-1000mg 6-8h for the elderly)
	Amp. 2mL (500mg/mL)
		Injectable: 2-5ml/day IV/IM
	Solution 500mg/mL
		Children:
	Suppository 300mg	20-25mg/kg every 6h
		(Maximum dose: 500mg)
		Newborns:
		10-15mg/kg every 6h
Paracetamol	Tablets 500 and 750mg	500-750mg every 6h	Hepatotoxicity (high doses, interactions with hepatotoxic drugs, alcoholics)	Avoid high doses in patients with severe renal and/or hepatic insufficiency.
		(Maximum dose: 4 g/day)
	Solution 200 mg/mL	Elderly:
		500-1000mg every 6-8h
		(Maximum dose: 2 g/day)
	Amp. 10mg/mL (50mL – Ameniflac ® and 100mL – Halexminophen ®)	Children:
		10-15mg/kg 4/4h
		(Maximum dose: 100mg/kg)
Viminol	Tablets 70mg	70-140mg Every 8h	Sedation, drowsiness, nausea, vomiting, addiction (low risk)	Avoid use in patients at risk at risk of addiction (psychiatric patients, illicit drug users, alcoholics)
				Requires A2 prescription (ANVISA)
Diclofenac	Tablets 50 and 100mg	50mg each 8-12 hs	Skin rash, epigastralgia, gastrointestinal bleeding, hypertension, edema, acute renal injury, cerebrovascular events	Avoid prolonged use in the elderly, in cases of cardiovascular diseases, chronic renal diseases, risk of bleeding (use of anticoagulants) and high gastrointestinal risk.
	Amp. 75mg/3mL
	Cream 10mg/g
Ibuprofen	Tablets 400 and 600mg	400mg each 4-6h	Skin rash, epigastralgia, GI bleeding, hypertension, edema, acute renal injury, cerebrovascular events	Avoid prolonged use in elderly, chronic cardiovascular diseases, chronic renal diseases, risk of bleeding (use of anticoagulants) and high gastrointestinal risk.
		600mg each 8h
		Children:
		4-10mg/kg every 6-8h
Tenoxican	Tablets 20 and 40mg	20-40mg each 24h	Skin rash, epigastralgia, gastrointestinal bleeding, hypertension, edema, acute renal injury, cerebrovascular events	Avoid prolonged use in the elderly, in cases of chronic cardiovascular diseases, chronic renal diseases, risk of bleeding (use of anticoagulants) and high gastrointestinal risk.
Celecoxib	Caps. 100 and 200mg	100-200mg every 12 h	Skin rash, epigastralgia, GI bleeding, hypertension, edema, acute renal injury, cerebrovascular events	Avoid prolonged use in the elderly, in cases of chronic cardiovascular diseases, chronic renal diseases, risk of bleeding (use of anticoagulants) and high gastrointestinal risk.
Naproxen	Tablets 200, 500 and 550 mg	250-550mg Every 12h	Skin rash, epigastralgia, gastrointestinal bleeding, hypertension, edema, acute renal injury, cerebrovascular events	Avoid prolonged use in the elderly, in cases of chronic cardiovascular diseases, chronic renal diseases, risk of bleeding (use of anticoagulants) and high gastrointestinal risk
		Children:
		5mg/kg every 12h
Ketorolac	Tablets 10mg	Up to 65 years-old:		Avoid prolonged use in the elderly, in cases of chronic cardiovascular diseases, chronic renal diseases, risk of bleeding (use of anticoagulants) and high gastrointestinal risk.
		Single dosing: 10- 20mg	Skin rash, epigastralgia, GI bleeding, hypertension, edema, acute renal injury, cerebrovascular events
		Multiple dosing: 10mg every 6-8h
		(Maximum dose 60mg/day)
		Over 65 years-old:
		Single dose: 10 a 20mg
		Multiple dosing: 10mg Every 6-8hs
		(Maximum dose 40mg/dia)
Meloxican	Tablets 7.5 and 15mg	15mg/day	Skin rash, epigastralgia, gastrointestinal bleeding, hypertension, edema, acute renal injury, cerebrovascular events	Avoid prolonged use in the elderly, in cases of chronic cardiovascular diseases, chronic renal diseases, risk of bleeding (use of anticoagulants) and high gastrointestinal risk.
Ketoprofen	Caps. 50mg	50mg every 8h	Skin rash, epigastralgia, gastrointestinal bleeding, hypertension, edema, acute renal injury, cerebrovascular events	Avoid prolonged use in the elderly, in cases of chronic cardiovascular diseases, chronic renal diseases, risk of bleeding (use of anticoagulants) and high gastrointestinal risk.
	Caps. LP 150mg	150mg twice a day
	Caps LR 100mg and 200mg	100mg every 12h or 200mg once a day
	Solution: 20mg/mL	50 drops every 6-8h
	Amp EV: 1mg/mL	100-300mg/day
	Amp. IM: 50mg/mL	100mg twice or thrice a day
	Gel: 25mg/mL	Twice or thrice a day (up to 15g/day)		Attention to skin care
		Up to 7 days
Loxoprofen	Tablet 60mg	60-120mg every 8h	Skin rash, epigastralgia, GI bleeding, hypertension, edema, acute renal injury, cerebrovascular events	Avoid prolonged use in the elderly, in cases of chronic cardiovascular diseases, chronic renal diseases, risk of bleeding (use of anticoagulants) and high gastrointestinal risk.
		(maximum dose: 180mg/day)
	Patch 100mg	1 patch per day		Avoid prolonged use in the elderly, in cases of chronic cardiovascular diseases, chronic renal diseases, risk of bleeding (use of anticoagulants) and high gastrointestinal risk.
Dexametasone	Tablets 2 and 4mg	2-4mg every 6h	Hyperglycemia, mental confusion, insomnia, hypertension, suppression of immune response, Cushing's syndrome, risk of fractures and osteoporosis, increased intraocular and arterial pressure, muscle weakness
		(Maximum dose: 16mg/day)
	Amp. IV and IM 2-4mg/mL
Baclofen	Tablet 10mg	5 -20mg every 8h	Dizziness, drowsiness, sweating, insomnia, dry mouth, vomiting, diarrhea	Increased risk of falls. Indicated in painful conditions associated with muscle spasticity
Cyclobenzaprine	Comp. 5,10,15mg	5-10mg once or twice a day	Cognitive dysfunction, sedation, delirium, orthostatic hypotension, dry mouth, blurred vision, constipation and urinary retention, cardiovascular effects	Central action muscle relaxant, molecular structure similar to tricyclics, use should be very careful in elderly, side effects similar to tricyclics, avoid use with serotonergic drugs due to risk of serotonin syndrome
	Caps. 15mg (Mitrul ®)	15mg once a day		Elderly: Long half-life about 12 to 24hs, consider another option
Tizanidine	Tablet 2mg	2-4mg thrice a day	Dry mouth, asthenia, dizziness, drowsiness	Short duration, lower risk of adverse effects, indicated in spasticity.
				Adjust dose in renal and hepatic insufficiency
Codeine	Tablet 30 and 60 mg	30-60 mg Every	Sedation, mental confusion, blurred vision, dry mouth, skin itching, constipation, urinary retention, addiction	10% of the population does not respond to codeine (cytochrome P450 polymorphism). Attention in patients with chronic renal disease
		4-6h
	Solution 3 mg/mL	(Maximum dose: 360mg/day)
		Elderly: 30-60mg every 6-8h
Codeine+ paracetamol	Tablet 500/7,5 and	1 tablet every 4h or 2 tablets every 6h
	500/30mg
Tramadol	Tablets and caps 50-100 mg	50-100mg every 4-6hs	Sedation, mental confusion, blurred vision, dry mouth, skin itching, constipation, urinary retention, addiction	May cause reduction of seizure threshold, avoid use in individuals with brain tumors or neurological conditions with predisposition to epileptic activities; risk of serotonin syndrome when associated with serotonin modulators; risk of hypoglycemia in the presence or absence of hypoglycemic agents and hyponatremia.
		(Maximum dose: 400mg/day)
		Eldery:
		50-100mg every 6-8h
	Solution 100mg/mL
	Tablets LP 50-100mg	50-100mg every 12h
Tramadol+ paracetamol	Tablets 37,5/325mg	1-2 tablets every 4-6hs		Association with paracetamol: Avoid high doses in patients with severe renal and/or hepatic insufficiency
		Eldery:
		1 tablet Every 6-8h
Rramadol+ diclofenac	Tablets 25/25mg;	1 tablet every 8h		Association with diclofenac: Avoid prolonged use in elderly, chronic cardiovascular diseases, chronic renal diseases, risk of bleeding (use of anticoagulants) and high gastrointestinal risk.
	50/25mg
Morphine		5-200mg every 4h	Sedation, mental confusion, blurred vision, dry mouth, skin itching, constipation, urinary retention, addiction	Attention in patients with chronic renal disease
	Tablets 10 and 30mg Amp. IV, SC 2 and 10 mg /mL
	Caps XR. 30, 60 and 100 mg	1 caps every 12h
Oxycodone	Tablets XR	1 tablet every 12h	Sedation, mental confusion, blurred vision, dry mouth, skin itching, constipation, urinary retention, addiction	Stable concentration in 24-36hs
	de 10, 20 and 40 mg
Oxycodone+ Naloxone	Tablets 5/2,5mg; 10/5mg; 20/10mg;
	40/20mg
Buprenorphine		5-20 mg every 7 days	Sedation, mental confusion, blurred vision, dry mouth, skin itching, constipation, urinary retention, addiction
	Transdermal patches	(Restiva®)		Stable concentration in up to 48hs. Compared to other opi oids, it has a good safety profile with low incidence of adverse effects in elderly, frail individuals and with polypharmacy
	5, 10, 20, 30 and
	40mg	20-40 mg every 3 days
		(Transtec®)

The role of opioids for acute analgesia

Opioids are important allies in controlling acute pain, including nociceptive (somatic or visceral), neuropathic, and mixed types, from various etiologies⁶,⁷ . They offer rapid and effective relief, and can be prescribed while adjuvants have not yet taken effect⁶ . Among the common side effects of opioids, constipation is the most prevalent, followed by nausea, vomiting, urinary retention, dry mouth, sedation, dizziness, and tolerance⁸ . Less commonly, cognitive alterations, delirium, hyperalgesia, myoclonus, pruritus, falls, cardiac, immunological, or hormonal changes, sleep disturbances, and euphoria may occur⁸ .

Overall, opioids have a good safety profile in the short-term⁶,⁹ . Although there are concerns about respiratory depression, this complication is considered rare when prescribed carefully¹⁰ . It is recommended to start with the lowest possible dose and gradually increase it as needed to achieve the best pain relief while minimizing adverse effects⁶ . In general, initial dosing should not exceed 50mg of oral morphine-equivalent (MME), and usually doses superior to 90MME do not provide clinically significant benefit to most patients with non-cancer pain (Table 2)¹¹,¹² . On the other hand, opioid efficacy is not well established in the long run, and may be undermined by tolerance¹³ . Also, long-term use is associated with significant side-effects in 78% of patients, of which 7,5% are considered to be severe, and leading to treatment drop-out in 14,1%¹³,¹⁴ .

Table 2
Oral morphine milligram equivalent doses for frequently prescribed opioids in Brazil.

Opioids	Conversion Factor
Codeine	0.15
Tramadol	0.2
Morphine	1.0
Oxycodone	1.5
Tapentadol	0.4
BuprenorphineA	70
MethadoneB
< 30MME	2
31-99 MME	4
100-299 MME	8
> 300	Consult with pain specialist

• MME – oral morphine milligram equivalent; Conversion factors based on Dowell¹¹ , unless otherwise specified; ^AConversion factor based on reference study⁶³ ; ^BConversion factor based on reference study¹² .

Notably, it is estimated that 2% to 5% may develop addiction with long-term use of these drugs¹⁴ . Therefore, special attention should be given to individuals with current or previous substance use disorders (including alcohol, tobacco, z-drugs and benzodiazepines), those with a family history of addiction, and patients with severe psychiatric disorders (including personality disorders), due to the high risk of abuse, misuse, and addiction related to opioids¹¹ .

Multimodal analgesia: translating the evidence from the transoperative to the outpatient setting

Taking into consideration the complexity and diversity of biological mechanisms underlying pain¹ , as well as the shortcomings of an analgesic strategy centered on opioid use, a conceptual shift in the framework of acute pain management has been undertaken in the past few decades¹⁵ . The use of multiple analgesic strategies, of distinct natures (e.g., pharmacological and non-pharmacological) and with differing mechanisms of action, defined as multimodal analgesia, has been increasingly recommended¹⁵ . Evidence stemming from perioperative pain management has shown that this strategy may lead to larger pain reduction, reduced opioid use, shorter hospital stays, and less side-effects¹⁶,¹⁷ . While most studies address post-surgical pain, data from these research may be useful to guide outpatient care. For example, a meta-analysis of results from seven trials, the bulk of which including patients with acute post-operative dental pain (a clinical setting which approximates acute pain outpatient care), the combination of paracetamol 650mg to tramadol 75mg resulted in better analgesia (NNT 2.6, 95%CI 2.3-3.0), when compared to isolated tramadol 75mg (NNT 9.9, 95%CI 6.0-17), without significant increase in reported side-effects¹⁸ . Furthermore, simple physical interventions, such as massage therapy, specific accuracy, joint manipulation and transcutaneous electrical nerve stimulation have been shown to provide significant analgesia for acute musculoskeletal pain¹⁹ , and may be useful to reduce drug consumption, improve pain outcomes and return to functionality.

Acute musculoskeletal pain

Musculoskeletal pain is the most frequent type of pain within the Brazilian population²⁰ , and encompasses several acute conditions commonly seen in daily practice: joint pain, tendonitis and myofascial pain syndrome⁹ . The assessment of these conditions should particularly include the evaluation of ergonomics (particularly during work and sleep) and lifestyle habits, physical activity, as well as their particular interference in the individual functionality⁹,²¹ .

The management of this type of pain should be approached multidimensionally, involving both pharmacological and non-pharmacological approaches, within an interdisciplinary focus. It should be highlighted that adequate management may reduce the risk of the development of structural and functional changes, that eventually result in a chronic course⁹ .

The pharmacological treatment should follow the Analgesic Ladder proposed by the World Health Organization (WHO) in 1986 and updated in the following years (Figure 1)²² . This strategy was developed with the primary goal of standardizing and optimizing pain treatment, especially in hospital settings²² . It provides a practical guide for the selection and dosage of analgesic drugs, aiming to relieve pain effectively and safely²² . For mild pain, treatment begins with non-opioid analgesics, which can be supplemented with adjuvants²²,²³ . If the pain persists, it progresses to weak opioids, with or without the initial drugs. Moreover, If pain is still not controlled, strong opioids should be considered²²,²³ .

Figure 1
Updated World Health Organization Analgesic Ladder.

This figure presents the updated version of the World Health Organization Analgesic ladder, the latter of which was originally proposed in 1986. While pain severity may guide the selection of the starting treatment step in acute pain and acute crisis of chronic pain, treatment of chronic pain should begin at the initial step, and progress to the next ones in case of refractoriness. In this updated version, an additional fourth step was included, recommending the consideration of analgesic and neuromodulation procedures to optimize analgesia in refractory or severe cases, and to reduce opioid requirements.

Paracetamol⁹,²³ pyrone and nonsteroidal anti-inflammatory drug (NSAID) are first-line drugs for managing mild to moderate acute pain⁹,²³ . These analgesics present a low risk of side effects and good tolerability, being indicated for pain related to muscle injuries and inflammations. Frequently used NSAIDs and their respective efficacy in treating acute pain according to the Oxford Pain Group are presented in Table 3²⁴ . Adjuvant drugs act synergistically with the other analgesics, favoring pain relief⁹,²³ . This therapeutic class is quite broad and, in the context of acute musculoskeletal pain, may include corticosteroids, antispasmodics, and muscle relaxants, among others⁹,²³ .

Table 3
Frequently used non-steroidal anti-inflammatory drugs in the outpatient setting and their efficacy in treating acute pain.

Drugs	Dose	Percent of patients with at least 50% pain relief	NNT (95%CI)
Diclofenac	100mg	67	1.9 (1.6 – 2.2)
	50mg	63	2.3 (2.0 – 2.9)
Ibuprofen	600mg	79	2.4 (2.0 – 4.2)
	400mg	56	2.4 (2.3 – 2.6)
	200mg	45	2.7 (2.5 – 3.1)
Ketorolac	20mg	57	1.8 (1.3 – 2.2)
	10mg	50	2.6 (2.3 – 3.1)
Naproxen	550mg	46	3.0 (2.2 – 4.8)

• Based on reference study²⁴ ; NNT – Number necessary to treat for achieving ≥ 50% pain reduction; 95%CI – 95% Confidence Interval.

Furthermore, musculoskeletal pain requires a broad approach to treatment beyond drug, primarily to avoid potential chronicity⁹,²¹ . Therefore, physical, psychological, and social rehabilitation is relevant, raising patient awareness of ergonomic, emotional, and psychosocial aspects⁹,²¹ .

Moreover, recently pain neuroscience education has gained increasing interest in the treatment of chronic musculoskeletal pain and may also be promising in acute settings, despite the lack of research to date²⁵,²⁶

It involves raising patient awareness, focusing on changing daily habits and routines that may influence the frequency and intensity of pain²⁵,²⁶ . Recent research has shown it to be effective when combined with exercises, acting to reduce pain intensity, disability, kinesiophobia, and pain catastrophizing compared to exercises alone²⁵,²⁶ .

Acute low back pain with and without sciatica

Acute low back pain (lumbago) is one of the most common musculoskeletal conditions globally²⁷ . In the primary care context, most cases of acute low back pain are non-specific and have a favorable prognosis. The main causes include disc herniation, lumbar canal stenosis, facet pain, and myofascial syndrome. Additionally, a portion of patients may progress to chronic pain or have severe underlying causes (e.g., fractures, infections, neoplasms, or cauda equina syndrome), making diagnostic, treatment, and management strategies crucial in initial care²⁸ .

In initial management, the diagnostic focus is to identify “red flags” that may indicate serious underlying pathologies, as well as to avoid unnecessary imaging in cases of non-specific low back pain²⁸ . International guidelines do not recommend routine imaging (X-ray, CT, or MRI) within the first 4-6 weeks of acute non-specific low back pain, in the absence of red flags²⁹ . There is strong evidence that early imaging rarely alters management or improves clinical outcomes²⁹ .

Strategies for treating acute low back pain are based on symptom reduction, functional restoration, and chronicity prevention, using a gradual and multimodal approach. It is important to clarify the benign and self-limiting nature of most cases of acute low back pain, and to encourage light physical activity within the individual limitations. Prolonged rest (beyond 48 hours) may delay recovery and increase risk of development of chronic pain³⁰ . Addressing psychosocial factors (e.g., fears related to pain, kinesiophobia, occupational stress) is also paramount as they can perpetuate the condition³⁰ .

The role of pharmacological treatment is limited in this condition. NSAIDs are considered as first-line therapy, as they lead to reduction in moderate functional improvements, although mild analgesia when compared to placebo. Additionally, the combination of vitamins B1, B6 and B12 with diclofenac has been observed to significantly improve the analgesic efficacy of this NSAID in treating acute low back pain and may be considered given its low-risk profile, although further studies are necessary to confirm these findings and their generalizability to other NSAIDs³¹-³³ . Paracetamol is not recommended, since systematic reviews have not demonstrated superior efficacy to placebo in acute low back pain³⁴ . Muscle relaxants (i.e., cyclobenzaprine, tizanidine): may provide modest short-term relief but are associated with adverse effects such as sedation and dizziness³⁴ . Moreover, opioids are not recommended routinely. They should be reserved for short-term use, in cases of severe and refractory pain, requiring strict supervision due to the potential risk of dependence and tolerance³⁴ .

On the other hand, non-pharmacological therapies should always be considered. Manual therapy (e.g., spinal manipulation, mobilization) and superficial heat therapy (warm compresses) can provide modest short-term symptomatic relief³⁰ . Physical therapy with emphasis on gradual exercises and postural guidance can also be beneficial²⁸ . Although structured exercises have not been found to lead to clinically significant benefit in the short term (up to 6 weeks), staying active remains fundamental for overall rehabilitation and recurrence prevention³⁰ .

The management of acute sciatica should be similar to acute low back pain in general. However, intense radicular pain may require epidural corticosteroid injections for temporary pain relief, even though functional long-term benefit is limited³⁵ . Discectomy may hasten sciatica pain improvement, but 1 year follow-up results tend to be comparable to conservative treatment³⁶ .

Most individuals will improve in 4 to 6 weeks. If this does not occur, or red flags appear, it is important to consider imaging³⁰ . Urgent referral to specialists is warranted in cases of suspected serious aethiologies or progressive neurological deficits²⁸ . For patients with acute sciatica, a conservative approach is recommended for at least 6-8 weeks, unless there are severe or progressive neurological deficits. In these cases, surgery may be discussed³⁰ .

Acute Herpes-Zoster

Herpes-zoster is a common medical condition, resulting from the reactivation of the Varicella Zoster virus lying latent in dorsal root and cranial nerve ganglia³⁷,³⁸ . Its lifetime prevalence is estimated to range from 15% to 30% in the United States, being more common among the elderly³⁹ . It usually affects the middle thoracic dermatomes and the ophthalmic division (V1) of the trigeminal nerve; resulting in a typical skin rash (i.e. maculopapular lesions with vesicles), and usually severe pain (37,40). Allodynia, pruritus and touch hypoesthesia are also commonly found⁴⁰ . It should be highlighted that, besides the acute symptomatic burden, herpes zoster may lead to significant complications, including cardio and cerebrovascular events, encephalitis, myelitis, retinitis and post-herpetic neuralgia³⁸,⁴¹ . The latter is defined as persistent local pain after 3 months since the beginning of the symptoms, and is reported to be the most frequent of these complications, occurring in up to a third of patients, especially the elderly and immunocompromised⁴² .

Acute management of this disease, and particularly of its painful symptoms, is frequently challenging, as it usually affects older individuals in whom changes in drug pharmacokinetics, metabolism, multimorbidity and polypharmacy are relevant aspects (“The elderly” topic section next). Its two main pillars are: antiviral treatment and pain management. Antiviral treatment involves oral guanosine analogues (Table 4) and should be ideally started within 72 hours of rash appearance, but can still be warranted outside this time window in case of development of new skin lesions, or if ophthalmic or neurologic complications are present³⁷ . For immunocompetent individuals with non-complicated herpes zoster (i.e., without ocular, otic, neurologic or other visceral involvement; nor extensive cutaneous manifestations, such as involving more than 2 contiguous dermatomes, or of bilateral and/or non-contiguous ones), treatment can be administered orally in the outpatient setting³⁸ . Adequate antiviral treatment reduces acute pain severity and duration, as well as the risk for most disease-related complications³⁸ . However, current evidence suggests it does not reduce the risk for developing post-herpetic neuralgia⁴³ .

Table 4
Antiviral recommended for acute herpes zoster treatment in the outpatient setting.

Drugs	Dosage (adult)	Adverse effects	Notes
Acyclovir	800mg orally 5 times per day for seven days	Diarrhea, encephalopathy, erythema multiforme, headache, malaise, nausea, Stevens-Johnson syndrome, vomiting	Dose adjustments warranted in case of creatinine clearance ≤ 50mL/min
Valacyclovir	1000mg orally thrice a day for seven days
Famciclovir	500mg orally thrice a day for seven days	Confusion, headache, nausea, Stevens-Johnson syndrome	Dose adjustments warranted in case of creatinine clearance ≤ 60mL/min

• Based on reference study³⁷ .

On the other hand, acute pain management strategy depends on pain severity, response to previous analgesic treatments, and individual aspects. Firstly, it is important to highlight that, although post-herpetic neuralgia is considered to be a typical prototype of neuropathic pain; nociceptive inflammatory pain is usually predominant in the early acute phases of the disease, giving way to more a more neuropathic component as it improves and the skin rash disappears. In this sense, mild to moderate pain should be managed with simple analgesics, NSAIDs with or without a weak opioid, such as tramadol³⁸ . Meanwhile, moderate to severe pain warrants use strong opioids³⁸ . In case initial pharmacologic treatment fails to bring significant pain improvement, a short corticosteroid course can be considered, usually with prednisone 60mg/day for 7 days. Gabapentin, pregabalin, tricyclic antidepressants³⁸ and, in the authors opinion, serotonin-noradrenalin reuptake inhibitors (e.g., duloxetine and venlafaxine) can also be considered. Topical analgesics, such as 5% lidocaine patches and creams may be recommended, when skin lesions have completely resolved. Finally, if pharmaceutical therapy still does not bring sufficient analgesia or are poorly tolerated, nerve blocks could be considered³⁸ .

Type-tension headache and migraine attacks

Type-tension headache and migraine are the most prevalent types of primary headaches and, as a group, they affect over 3 billion people worldwide, being the second most common disease conditions and the third cause of years lived with disability globally⁴⁴ . However, acute treatment of these headache attacks is frequently overlooked. It is estimated that over 60% of people suffering from migraine have never used acute prescription pharmaceuticals⁴⁵ . Moreover, among individuals receiving them, 37.4% reported dissatisfaction with their treatment regimen⁴⁶ . This is particularly concerning if taken into consideration that adequate acute headache attack treatment does not only reduce the disease burden but may also play an important role in the risk for their evolution to chronic forms. In fact, among people suffering from episodic migraine, the risk for developing chronic daily headache (i.e., over 15 headache days per month), was found to be twice as large among those who reported poor outcomes with acute treatment⁴⁷ .

It should be highlighted that acute headache treatment should be offered to all people suffering from migraine or tension-type headache⁴⁸-⁵⁰ , aiming at: i. fast and consistent freedom from pain and associated symptoms, without recurrence; ii. restored ability to function; iii. minimal need for repeat dosing or rescue drugs; iv. optimal self-care and reduced subsequent use of resources (e.g., emergency department visits); and, v. minimal or no adverse events⁵¹ .

For acute migraine treatment, first-line drugs include simple analgesics and NSAIDs⁴⁸,⁴⁹ . If this is found to be insufficient, triptans should be prescribed (Table 5)⁴⁸,⁴⁹,⁵² . If adequate pain relief cannot be obtained with optimized doses of the selected triptan in two out of three attacks, the switch to another triptan is recommended⁴⁹ . Notably, the combined use of NSAIDs and triptans, particularly of sumatriptan and naproxen, has been found to act synergically in improving pain outcomes, and can be recommended as an alternative to optimize results⁴⁹ . Triptans are contraindicated in patients with cardiovascular or cerebrovascular diseases, uncontrolled hypertension, hemiplegic migraine and migraine with brainstem aura⁴⁸ . Ergot derivates, such as dihydroergotamine, could be considered if all other available treatments do not yield adequate pain relief⁴⁹ . However, their variable bioavailability, high risk for drug interactions and overuse, and frequent side effects (e.g., nausea and vomiting) usually limit their use⁴⁹ . Opioids are strongly not recommended for management of migraine, as they have not been found to be superior to other treatment alternatives, and their overall risk-benefit ratio to be unfavorable in this setting⁴⁹,⁵³ . Finally, in case of migraine attacks lasting for more than 72 hours (i.e., status migrainosus), parenteral treatment are often warranted within the emergency department settings, and may include: NSAIDs, chlorpromazine and other antidopaminergic agents, magnesium, steroids and peripheral nerve blocks⁴⁹ . The detailed management of status migranosus is beyond the scope of this article.

Table 5
Triptans recommended for treatment of migraine attacks available in Brazil.

Drugs	Initial dosing	Maximum daily dose	Notes
Sumatriptan	50-100mg (may repeat in ≥ 2h)	200mg	---
Zolmitriptan	2.5-5mg (may repeat in ≥ 2h)	10mg	---
Eletriptan	20-40mg (may repeat in ≥ 2h)	80mg	A minimum of 40mg is generally recommended due to higher efficacy Avoid if us of CYP3A4 inhibitor within 72h
Rizatriptan	5-10mg (may repeat in ≥ 2h)	30mg	Reduced dose (5mg per dose and 15mg/24h) is recommended in case of use of propranolol
Naratriptan	2.5mg (may repeat in ≥ 4h)	5mg	Slower onset and longer duration of effect May have lower efficacy, but better tolerability

• Based on reference study⁵² .

Additionally, some important considerations should be made for the management of migraine attacks in the outpatient setting. Firstly, antiemetic drugs should be offered to all individuals who suffer from nausea and/or vomiting that is not manageable with timely intake of acute attack drug⁴⁹,⁵¹ . The available oral antiemetic drugs most recommended for this purpose are: metoclopramide, domperidone, promethazine and chlorpromazine⁴⁹ . The combination of antiemetics with NSAIDs and/or triptans has been found to improve acute migraine treatment efficacy⁴⁹,⁵¹ . Also, if the individual experiences early vomiting during the attack, parenteral route and orally disintegrating tablets should be favored, if available⁴⁹ . Secondly, acute drugs should be used as early as possible, preferably while pain intensity is still mild, as this strategy has been consistently shown to improve outcomes⁴⁹ . Finally, patients should be recommended to restrict limiting simple analgesic and NSAID use to less than 3 days per week, and triptan, ergot derivates and combined analgesics (i.e., simple analgesics with caffeine) to less than 2 days per week, in order to reduce the risk of developing drug overuse headache⁴⁹ . It should be noted that, individuals with more than three headache days per month may warrant optimization of prophylactic treatment⁵¹ .

On the other hand, tension-type headache should be managed with simple analgesics or NSAIDs⁵⁰,⁵⁴ . While the latter have been found to be more efficacious, the isolated use of the former could be considered in milder cases, given their favorable tolerability profile⁵⁰,⁵⁴ . Although caffeine alone does not provide benefit in treating tension-type headache attacks, its combined use with paracetamol or NSAIDs has been shown to improve outcomes⁵⁴ . As for migraine, opioids are not recommended⁵⁰,⁵⁴ . Furthermore, triptans, ergot derivates and muscle relaxants are not efficacious for this type of headache and should not be recommended⁵⁰,⁵⁴ .

Special populations

a. The elderly

The management of pain in elderly people is often challenging, as this population undergoes numerous biopsychosocial changes that may change drugs pharmacokinectics, including: increases in the body fat percentage (thus leading to larger distribution volumes for lipophilic drugs, such as opioids, which tend to accumulate and present with higher elimination half-lives); reduction in phase I hepatic metabolism; and reductions of renal clearance⁵⁵,⁵⁶ . Furthermore, they often suffer from communication difficulties, cognitive decline, sensory deficits, multimorbidity, social and family insufficiency, and polypharmacy, adding a layer of complexity to the management⁵⁷ . Particularly, in Brazil, a study observed that 93.0% of the elderly were using at least one drug chronically, and that about 18.0% were in use of at least five⁵⁸ . Drug consumption, associated with a higher burden of diseases, as well as changes inherent to aging, produces side effects and drug interactions with serious consequences for patients in this age group⁵⁹ . These factors need to be carefully considered when new treatments are being introduced to minimize the risk of drug interactions and severe adverse reactions⁵⁵,⁵⁶,⁵⁹ . In this sense, a “start low and go slow” approach is generally recommended when introducing drugs, with frequent assessments of side effects and analgesic efficacy. Additionally, care should be taken when prescribing analgesic drugs as to changes in posology due to increases in drug half-life (Table 1). Finally, non-pharmacological treatments should be considered whenever possible.

b. Children and adolescents

Acute pain management in pediatrics is complex, as the pediatric age range encompasses infants to adolescents. Safe and effective pharmacological management requires an understanding of pharmacological principles within this population, taking into consideration age, pain severity, developmental stage, patient individuality, drug characteristics. On the other hand, untreated pain in children, especially in neonates, can have lasting consequences⁶⁰ . Studies indicate that repeated exposure to pain during the first days of life can lead to chronic sensitization to painful stimuli and changes in the central nervous system⁶⁰ . Children suffering from chronic pain are also at greater risk of developing emotional problems, mood disorders, and socialization difficulties⁶¹ .

Assessing pain in children is frequently challenging, as there may be no or poor verbal communication, and it may be expressed in other ways (e.g., withdrawal, minimizing pain due to fear, apathy, or aggression). In neonates and infants, clinical judgment combined with the use of age-appropriate scales is necessary, while simple assessment scales are useful in older children⁹ .

The management of acute and chronic pain in children is increasingly characterized by a multimodal or preventive analgesia approach, in which lower doses of non-opioid and opioid analgesics, such as NSAIDs, local anesthetics, N-methyl-D-aspartate antagonists, alpha-adrenergic agonists, and voltage-dependent calcium channel alpha-2 delta proteins are used, alone or in combination with opioids, to maximize pain control and minimize drug-induced adverse side effects⁶² . Initial management of acute pain in pediatrics is based on the use of simple analgesics and NSAIDs (Table 1)⁶² . Additionally, psychological pain management, such as distraction, hypnosis, and relaxation techniques, has shown efficacy in relieving acute and chronic pain in children⁶² .

c. Pregnant and breastfeeding women

Various anatomical and functional changes occurring during the gestational period can trigger, exacerbate, or modify a wide range of painful conditions, particularly musculoskeletal disorders⁹ . In this context, the choice of the most appropriate therapeutic intervention for each situation is based on providing analgesia with minimal risk to the pregnant person and the fetus⁹ .

Whenever possible, non-pharmacological measures should be prioritized, avoiding or postponing pharmacological or surgical interventions. Drugs used during pregnancy may be present in the fetal circulation at birth, alter placental blood flow, and cause fetal damage by reducing the supply of oxygen and nutrients⁹ . When determining pharmacological treatment, it is important to consider maternal gestational age, the placenta, and the fetus. Drugs with a high protein binding rate are excreted in small amounts in breast milk⁹ .

Dipyrone and paracetamol are among the non-opioid analgesics used during pregnancy and breastfeeding. Paracetamol at doses > 3 g/day for prolonged periods can cause liver and kidney damage in both the mother and the fetus⁹ . The use of NSAIDs should be avoided from the third trimester onward, as they can prolong pregnancy, and can cause premature closure of the ductus arteriosus, neonatal pulmonary hypertension, fetal oliguria, oligohydramnios, facial dysmorphisms, disturbances in fetal homeostasis, and muscle contracture⁹ . However, during breastfeeding, ibuprofen, diclofenac, ketoprofen, meloxicam, and mefenamic acid are compatible at usual doses. For detailed information on prescribing drugs during pregnancy and lactation, it is recommended to consult the risk classification based on the drug's potential to cause fetal malformations, developed by the US Food and Drug Administration, as well as the Australian Drug Evaluation Committee classification, which categorizes the risk of drugs used during pregnancy⁹ .

CONCLUSION

Although acute pain management is part of the daily practice, it can be frequently challenging, especially when addressing specific patient populations (i.e., neonates, children and the elderly). Nonetheless, adequate acute pain control is paramount to preventing the development of chronic pain, besides reducing the symptomatic burden of their underlying disease. To achieve that aim, adequate knowledge of the available pharmacological treatments, engagement in non-pharmacological approaches, implementation of multimodal analgesia strategies and therapy individualization are required.

ACKNOWLEDGEMENTS

The authors would like to thank the Brazillian Society for the Study of Pain for the support and organization of discussion panels that led to the development of this review and its recommendations.

• Sponsoring sources:
  none.

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Edited by

• Associate editor in charge:
  Ana Flávia Vieira Leite https://orcid.org/0009-0007-1747-1078

Publication Dates

• Publication in this collection
  22 Aug 2025
• Date of issue
  2025

History

• Accepted
  20 June 2025
• Accepted
  29 July 2025