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Q: I have persistent pain on the left side of my body just below my rib cage. It feels like it starts in the back and wraps around to the front.

I had an abdominal CT scan, which didn’t show anything that might cause the pain. What else might cause this and what can be done about it?

A: What you describe is actually quite common. It sounds like your pain might be coming from one of the nerves 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.

The pain can be very severe. In addition, nerve pain often has a very irritating quality that can be even more uncomfortable than pain due to other causes.

Treating persistent nerve pain can be frustrating. There is no 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 keeping costs low.

When cost is an issue, I usually suggest a combination of a generic nonsteroidal anti-inflammatory drug (NSAID) and a low dose of one of the tricyclic antidepressants, such as amitriptyline.

If you cannot take NSAIDs because of an allergy, kidney problems, gastritis or peptic ulcer disease, generic 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.

When I prescribe a tricyclic antidepressant for pain, patients often tell me, “But I’m 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, so 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.

You can also try topical lidocaine or capsaicin applied to the skin.

Other medications you can discuss with your doctor include duloxetine (Cymbalta), gabapentin or pregabalin (Lyrica).

Also, relaxation techniques and mindful meditation can be helpful for anyone with chronic pain.

Howard LeWine, M.D., is an internist at Brigham and Women’s Hospital in Boston and assistant professor at Harvard Medical School. For additional consumer health information, visit health.harvard.edu.

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