What should you do when sciatica flares?

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People with diagnosed sciatica have no trouble recognizing a flare-up. It strikes as numbness, tingling, or pain in the buttock and down the leg, caused by irritation to the sciatic nerve, which begins in the spine and travels downward into the leg.

While it's easy to identify a flare-up, it's trickier to tamp it down. It may take a combination of approaches to ease discomfort.

What is sciatica?

Sciatica is the term for discomfort caused by irritation of the sciatic nerve. This nerve starts at each side of the low back and extends down through the buttocks, back of the thigh, and lower leg.

Irritation usually occurs in the spine, with one of the nerve roots that eventually form the sciatic nerve. Anything pressing against a nerve root — such as a bony growth from arthritis in the spine or a bulging disc in between the spinal bones — can inflame the nerve root and send pain, numbness, or tingling all the way down one of the sciatic nerves.

"If you've never had it before, it's common to worry that you may have damaged your sciatic nerve. It's usually more of an irritation, however, as opposed to an outright injury," says Dr. Max Epstein, a physiatrist at Spaulding Rehabilitation Hospital. "But if you also experience muscle weakness or significant changes to your bowel or bladder habits, that could be a sign of nerve damage. In either case, you should speak to a health care provider as soon as possible."

Pill-free approaches

Coping with sciatica discomfort starts with pill-free strategies that you can try immediately.

Stay active. One of the most important things you can do when sciatica flares is to avoid bed rest. "Part of low back pain is muscle-related, possibly because muscles surrounding the irritated nerve roots tighten and try to protect the area. Movement keeps the muscles loose and working correctly. If you don't move, they can get tight and increase pain," says Dr. Max Epstein, a physiatrist at Harvard-affiliated Spaulding Rehabilitation Hospital.

Modify activities. If activity is painful, do only what you can tolerate. "Think of a green, yellow, or red zone of pain. The green zone is a mild amount of pain while doing an activity. That's okay. But if you get into the yellow zone, it's time to pull back and modify an activity," Dr. Epstein says. "For example, if it hurts to carry a full laundry basket, take out a few things. Or if it's painful to stand at the sink and do dishes, open the cabinet below the sink and rest your foot on the bottom of the cabinet. That will take tension off the nerve."

Stretch. Keep the muscles loose and limber with gentle stretching, but only within the green zone of pain. For example, you might stand and try to touch your toes to stretch your back and leg muscles. Or try some yoga poses. Dr. Epstein recommends the cat-cow: Get down on all fours, with your hands directly beneath your shoulders and your knees beneath your hips. Inhale and lift your head and tailbone toward the ceiling, while curving your lower spine toward the floor. As you exhale, round your back, bringing your chin toward your chest and tucking your tailbone under. Repeat the exercise 10 times.

Use hot or cold therapy. Hot or cold therapy for sciatica can take many forms. For example, you might soak in a warm bath or apply a hot pack or a cold pack to your leg or back. "What works for one person might not work for another, so you may have to experiment to see what's best for you," Dr. Epstein says. How does it help sciatica? "Heat may loosen muscles, and cold may tamp down inflammation, but we don't know for sure," Dr. Epstein explains.

Relaxation. Staying relaxed is an important part of controlling both acute pain (the kind that's sudden and temporary) or chronic (ongoing) pain.

"All pain is processed in the mind. If you're able to calm the processing centers, the perception of pain may decrease," Dr. Epstein says. He recommends trying breathing exercises, meditation, yoga, or tai chi. Practicing mindfulness — focusing attention on the present moment — might also help ease discomfort by helping you to accept it.

Drugstore remedies

Several over-the-counter remedies can also play a part in relieving sciatica.

Oral painkillers. Oral nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Advil, Motrin) help reduce inflammation, which reduces pain. But they may cause stomach ulcers and bleeding, liver or kidney damage, or an increased risk of heart attacks. So get your doctor's okay before using them, and find out the dose and frequency that's safe for you.

Acetaminophen (Tylenol) is often less effective at relieving sciatica pain than NSAIDs, but it's also less risky — unless you take it in very high doses, which can cause liver damage. The usual limit is no more than 3,000 milligrams (mg) per day, but your doctor might set a lower limit depending on your health.

Topical painkillers. Applying painkillers to your skin as creams, gels, or patches can also bring sciatica relief. Topical NSAIDs such as diclofenac gel (Voltaren) may have fewer risks than NSAID pills, since topicals stay close to the site of application and aren't well absorbed by the rest of the body. But it's still wise to check with your doctor before using them. Other types of topicals with fewer risks than NSAIDs include creams, sprays, and patches that contain anesthetics such as lidocaine; pain signal interrupters such as menthol or capsaicin; or arnica gel, an herbal remedy thought to have anti-inflammatory properties.

Turmeric supplements. Turmeric (a golden-yellow spice) contains curcumin, which appears to have anti-inflammatory and antioxidant properties. "Although there have not yet been studies that prove its benefit, it's the one supplement that I would support for pain relief. There's no clear recommendation for dosage, but 1,000 mg per day might help. You can take it all at once or break it up into morning and evening doses," Dr. Epstein says.

Call your doctor

A typical flare-up lasts for a few days to a week or two. If it's not improving or responding to home remedies, it's time to make an appointment with your doctor.

Your doctor might order imaging tests and prescribe a prescription anti-inflammatory drug, such as oral or injected prednisone. "That will buy you a window of time to strengthen muscles without pain, and keep them flexible," Dr. Epstein says. "That will help keep your body strong and protected, so you'll be in a better place than where you started."

What if you don't reach out for help? "At times the nerve stays irritated for years," Dr. Epstein says. "So try not to delay treatment. Usually our interventions are able to put out the fire or at least calm the severity of the symptoms in a meaningful way."

If you'd like more information, check out the Harvard Special Health Report Finding Relief for Sciatica (/frfsc).