Neuropathic Pain

Neuropathic pain is caused by abnormal functioning of the sensory nerves delivering abnormal and painful signals to the brain.

 

Presentation

Neuropathic pain can affect a wide variety of areas with number of different causes:

  • Postherpetic neuralgia from shingles is in the distribution of a dermatome and usually on the trunk
  • Nerve damage from surgery
  • Multiple sclerosis
  • Diabetic neuralgia typically affects the feet
  • Trigeminal neuralgia
  • Complex Regional Pain Syndrome (CRPS)

Typical Features

  • Burning
  • Tingling
  • Pins and needles
  • Electric shocks
  • Loss of sensation to touch of the affected area

 

DN4 Questionnaire

This is used to assess the characteristics of the pain and examination of the affected area. They are then scored out of 10 for their pain. A score of 4 or more indicates neuropathic pain.

 

Management

There are four first line treatments for neuropathic pain:

  • Amitriptyline is a tricyclic antidepressant
  • Duloxetine is an SNRI antidepressant
  • Gabapentin is an anticonvulsant
  • Pregabalin is an anticonvulsant

 

NICE recommend using one of these four medications to control neuropathic pain. If that does not work then stop and start an alternative and repeat this until all four have been tried.

 

Other options

  • Tramadol ONLY as a rescue for short term control of flares
  • Capsaicin cream (chilli pepper cream) for localised areas of pain
  • Physiotherapy to maintain strength
  • Psychological input to help with understanding and coping

 

Trigeminal neuralgia is a type of neuropathic pain however NICE recommend carbamazepine as first-line for trigeminal neuralgia and if that does not work to refer to a specialist.

 

Complex Regional Pain Syndrome

This is a condition where areas are affected by abnormal nerve functioning causing neuropathic pain and abnormal sensations. It is usually isolated to one limb. Often it is triggered by an injury to the area.

The area can become very painful and hypersensitive even to simple inputs such as wearing clothing. It can also intermittently swell, change colour, change temperature, flush with blood and have abnormal sweating.

Treatment is often guided by a pain specialist and is similar to other neuropathic pain.

Last updated February 2019
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