BACKGROUND: The most effective treatment for pain in prehospital adults remains uncertain. This scoping review aimed to descriptively synthesize the evidence and identify research gaps regarding pain interventions for adults in prehospital settings. METHODS: We searched MEDLINE, EMBASE, CINAHL, the Cochrane Library, and TRIP on 11 April 2025. Systematic reviews of adults receiving a pain intervention in the prehospital setting were included. We defined prehospital pain in this review as adults (18 years or >) treated for pain by a healthcare professional in the out-of-hospital setting from the time of first contact at the scene until emergency department admission. AMSTAR 2 was used to assess quality. RESULTS: There were 22 systematic reviews (n = 193 primary studies, n = 93,092 adults) included that assessed 24 interventions including fentanyl (n = 9 reviews, 41%), ketamine (n = 9, 41%), morphine (n = 7, 32%), ketamine plus morphine (n = 7, 32%), fascia iliaca nerve block (n = 5, 23%), methoxyflurane (n = 5, 23%), nitrous oxide (n = 5, 23%), sufentanil (n = 4, 18%), tramadol (n = 4, 18%), paracetamol (n = 3, 14%), alfentanil (n = 2, 9%), femoral nerve block (n = 2, 9%), ibuprofen (n = 2, 9%), pentazocine (n = 2, 9%), transcutaneous electrical nerve stimulation (n = 2, 9%), auricular acupressure (n = 1, 5%), butorphanol (n = 1, 5%), hydromorphone (n = 1, 5%), ketamine plus nitrous oxide (n = 1, 5%), meperidine (n = 1, 5%), metamizole (n = 1, 5%), papaveretum (n = 1, 5%), and traction/splinting (n = 1, 5%). A third (38%; n = 8) of reviews conducted meta-analyses; median = 876 participants (IQR: 320–1538). However, no meta-analyses met the threshold of 5126 participants deemed necessary following trial sequence analysis. The quality of reviews was high (n = 8, 36%), moderate (n = 9, 41%), low (n = 2, 9%), and critically low (n = 3, 14%). CONCLUSIONS: Larger pragmatic trials using a single validated pain scale with interventions administered at standardized time intervals are required to facilitate evidence synthesis and evidence-based decision-making for pain management in prehospital settings. STUDY PROTOCOL PRE-REGISTRATION: https://doi.org/10.17605/OSF.IO/MH7Q9 . SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s12873-026-01491-1.