An Overview of Neuropathic Pain

Neuropathic pain or nerve pain is one of the most intense types of chronic pain, often described as sharp, stinging or burning. It is pain caused by damaged nerves or a problem with the nervous system. While neuropathic pain can be debilitating, the upside is that there are medications to treat it, and they work by changing the way the brain interprets pain.

There are many terms used to describe neuropathic pain, such as:

• Sharp
• Shooting or "electrical shock"
• Burning or "hot"
• Tingling or "pins and needles" or "prickling"
• Stabbing

Neuropathic pain can occur all the time or come in spurts. Likewise, neuropathic pain can range in intensity from being mild and nagging to severe and disabling.

Interesting, neuropathic pain tends to be worse at night, which may disrupt your sleep. It also tends to flare at rest, which may affect relaxation or meal time. Overall, the negative impact neuropathic pain has on one's quality of life can lead to psychological problems, such as depression and anxiety.

There are many reasons why a person may develop neuropathic pain. For instance, some types of neuropathic pain are caused by medications, like certain chemotherapies. Others may be the result of a disease that affects the nervous system, like Guillain-Barre syndrome, cancer, multiple sclerosis, multiple myeloma, alcoholism, and HIV.

Neuropathic pain is also common in diseases, such as diabetes, that attack sensory nerves, and in conditions where certain nerves are inflamed or compressed, as in carpal tunnel syndrome or sciatica. Nerve pain may also result from trauma, like with spinal cord injury, where nerves are damaged or severed.

Phantom limb pain is another neuropathic pain disorder in which pain feels as if it is coming from a limb that was amputated.

Unfortunately, some types of neuropathic pain have an unknown origin or a cause that is not completely understood. Reflex sympathetic dystrophy (CRPS) is an example. Though the cause may not be fully known, the pain is very real.

The diagnosis of neuropathic pain requires a detailed medical history and physical examination. While the "why" behind a person's neuropathy can often be deciphered clinically (from the history and exam, alone), sometimes the diagnosis requires an evaluation by a specialist, like a neurologist. In this instance, the diagnosis may require more testing including blood tests, nerve tests like an electromyography (EMG), or imaging tests, like a magnetic resonance imaging (MRI) of the brain or spinal cord.

Treatment of neuropathic pain first entails addressing the underlying problem. For example, if a person has neuropathic pain from diabetes, optimizing blood sugar (glucose) control is an essential next step. Bear in mind, though, enhanced glucose control cannot generally reverse the neuropathy, although it can prevent it from getting worse and ease current symptoms.

Another example is if a medication is causing debilitating nerve pain. In this case, removal or a decrease in the dose of the offending drug may be all that is needed.

First-Line Medications

Besides treating the underlying problem, medication is often needed to manage neuropathic pain.

For the vast majority of patients, treatment of neuropathic pain involves taking one of the following:

• An antidepressant like Cymbalta (duloxetine) or Elavil (amitriptyline)
• An anti-seizure medication like Neurontin (gabapentin) or Lyrica (pregabalin)

Side Effects

In terms of side effects, nausea is the most common side effect of Cymbalta. Elavil generally poses more of a problem, mostly because of its risk for heart toxicity, as well as other bothersome side effects, including:

• Dry mouth
• Constipation
• Urinary retention
• Feeling lightheaded or dizzy when standing up

Neurontin may cause dizziness, tiredness, confusion, and swelling in the lower legs. Lyrica may cause dizziness, tiredness, dry mouth, swelling, and blurry vision.

Second-Line Medications

Opioids like Vicodin (hydrocodone/paracetamol) and Percocet (oxycodone/acetaminophen) are not as effective for treating neuropathic pain, and thus, are considered second-line treatments. In addition to their questionable benefit, opioids are associated with several side effects.

Side Effects

The potential side effects of opioids may severely affect a person's quality of life and include:

• Nausea and vomiting
• Constipation
• Itching
• Dry mouth
• Urinary retention
• Drowsiness
• Memory and thinking problems
• Slowed breathing

In addition to these side effects, there is a nationwide concern for opioid addiction and abuse.

Unique Therapies

There are some types of neuropathic pain that may require a unique treatment plan.

For instance, if a person's neuropathic pain is localized, as is often the case in postherpetic neuralgia, a topical (on the skin) therapy, like a lidocaine patch may be used.

In other instances, surgery may be necessary—for example, to release a compressed nerve, as in carpal tunnel syndrome. In the case of a herniated disc, in which an inflamed spinal nerve is a culprit behind the pain, an epidural steroid injection into the spine is sometimes performed.

Lastly, sometimes certain medications are used to treat specific neuropathic pain conditions. A classic example is trigeminal neuralgia, which is characterized by severe, stabbing neck and facial pain. This disorder is treated with the anti-seizure medication, Tegretol (carbamazepine) or Trileptal (oxcarbazepine).

Complementary Therapies

There are a variety of complementary therapies that can help relieve neuropathic pain. These therapies are commonly used in combination with medications and include:

• Physical or occupational therapy
• Relaxation therapy
• Massage therapy
• Acupuncture

Neuropathic pain is often chronic and can be challenging to treat. The good news is that there are a lot of treatment options, and often it's the combination of therapies that does the trick. With that, remain persistent in your efforts to soothe your pain—but also aware that it's often a trial and error process.