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

Kubota, Gabriel Taricani; Dietrich, Daniela Costa Martins; Barros, Bianca Figueiredo; Correia, Luci Mara França; Viotto, Ana Clara de Albuquerque Botura; Serrano, Sandra Caires

doi:10.63231/2595-0118.20250039-pt

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REVIEW ARTICLE • BrJP 8 • 2025 • https://doi.org/10.63231/2595-0118.20250039-en linkcopy

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

Authorship SCIMAGO INSTITUTIONS RANKINGS

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

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)
Viminol	Tablets 70mg	70-140mg Every 8h		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
	Gel: 25mg/mL	Up to 7 days		Attention to skin care
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.
	Tablet 60mg	(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
	Comp. 5,10,15mg	5-10mg once or twice a day
	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.
Tizanidine	Tablet 2mg	2-4mg thrice a day	Dry mouth, asthenia, dizziness, drowsiness	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
Codeine+ paracetamol	500/30mg	1 tablet every 4h or 2 tablets every 6h
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.
Rramadol+ diclofenac	50/25mg	1 tablet every 8h
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
Oxycodone	de 10, 20 and 40 mg
Oxycodone+ Naloxone	Tablets 5/2,5mg; 10/5mg; 20/10mg;
Oxycodone+ Naloxone	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®)

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

Drugs	Dose	Percent of patients with at least 50% pain relief	NNT (95%CI)
Diclofenac	100mg	67	1.9 (1.6 – 2.2)
Diclofenac	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)
Ketorolac	10mg	50	2.6 (2.3 – 3.1)
Naproxen	550mg	46	3.0 (2.2 – 4.8)

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

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

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[1] 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 .