Timothy C. Hain, MD Page last modified:
May 28, 2012
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This page is a brief overview of treatments of peripheral nerve pain.
Neuralgia quite simply is pain caused by damage to nerves. It can be exquisitely
painful.Trigeminal neuralgia is the most common type. The symptoms typically include
lightning like jolts of pain in the face. The pain usually lasts for 10 seconds or less.
It may be triggered by chewing, talking, or other facial movements. One may experience 100
attacks of trigeminal neuralgia throughout the day.
Similar but much less common to
trigeminal neuralgia is glossopharyngeal neuralgia. Here, the nerve involved affects the
throat and ear.
Post-herpetic neuralgia is also common. It is usually follows an attack of
"zoster", which is a second attack of the chickenpox virus. About 15% of people
who have had chickenpox develop zoster sometime during their life, and about 10% of people
with zoster develop neuralgia. In older adults, as many as 50% develop neuralgia, one or
more months after the rash. The pain of post-herpetic neuralgia is usually constant and
Occipital neuralgia is usually due to trauma to the occipital nerve,
often caused by a whiplasy type auto-accident. Here, there are paroxysms
of severe occipital pain, that often resemble severe migraines.
Occipital neuralgia can sometimes be successfully treated with blocks
of the occipital nerve, sometimes followed by radio-frequency
ganglioneurectomy. Medications are usually not helpful for
What tests are appropriate for Neuralgia ?
In most instances no tests at all are needed. An MRI or CT scan of the skull base is
the most common test.
How is neuralgia treated ?
Neuralgia can be extremely painful, and there are several approaches. In general
a approach combining several classes of drugs is used.
Oral medications for nerve pain
Aspirin or acetominophen, nonsteroidal analgesics such as Torodol, and narcotics are
frequently used for neuralgia. Usually non-narcotic pain killers are not strong enough to
control neuralgia pain, but they are worth a try anyway. Narcotic medications are
addictive and there is usually an attempt to use other medications first. However, it is
clear that they are reasonably effective (Pappagallo and Campbell, 1994).
Topical medications for nerve pain
In general, topical treatment for nerve pain is a good idea. It avoids many side effects, and addiction.
- Zostrix is a cream that is
available over the counter. It us used both for arthritis and post-herpetic
neuralgia. It is not used for trigeminal neuralgia. It starts to work only after
four days of application. Zostrix works by depleting substance P from nerve
- Xylocaine preparations, such as are used for sunburn, are also sometimes used.
5% lidocaine Gel has been studied and shown to have good results with no side
effects (Rowbotham et al, 1995).
- Aspirin dissolved in chloroform is used in some countries for neuralgia. The
technique is to crush aspirin tablets, dissolve them in chloroform, and apply
to the painful area (King, 1993). According to Rubin (2001), there is conflicting
evidence regarding Zostrix, and the aspirin preparation alluded to above is
of "questionable value".
- EMLA cream has also been used.
- A ketamine lotion has been reported effective for postherpetic neuralgia. Soybean
lecithin granules (250g Spectrum LE 102) were mixed with 150 ml isopropyl palmitate
and stirred at least 12 hours. Ketamine (10 ml) was added to a final concentration
of 5mg ketamine/mol gel (Quan et al, 2003). Ketamine has also been found useful
via other routes.
lidocaine patch has been approved by the FDA for pain. It has been our
observation that this method is effective but extremely expensive.
Anticonvulsants used for pain.
These are commonly used for trigeminal neuralgia.
Tegretol (carbamazepine), Dilantin (phenytoin), and Neurontin
(gabapentin) are the most commonly used drugs (Robotham et al, 1998).
The author of this review often uses Trileptal (oxcarbamazine). They
are given in doses similar to used for epilepsy, but more leeway is
given to the patient in adjusting the dose up and down, depending on
the amount of activity of the neuralgia. Sodium Valproate has also been
used for this purpose. Recently, oxcarbazepine (Trileptal) has become
available. Although it is not FDA approved for this indication, it
behaves similarly to carbamazepine. Adjunctive agents may be used in
this situation. These include baclofen and amitryptyline (see
Antidepressants used for pain.
These are mainly used for post-herpetic neuralgia.
Amitriptaline is the most commonly used. Nortryptaline, Desipramine and
others can also be used. Some authors claim that amitryptaline should
be started within 3-6 months of onset of shingles to get optimal
relieve (Bowsher, 1994). SSRI type antidepressants don't appear to work
according to one author (Max MB, 1994), and may be effective according
to several others. SNRI type antidressants such as Cymbalta are used
for neuropathic pain. It has been suggested that for this use,
beta-blockers should be avoided (Yalcin et al, 2009)
Antiviral agents and steroids.
Some authors feel that flareups of trigeminal neuralgia may be alleviated by
use of acyclovir or better, closely related antiviral medications (e.g. famvir,
valcyclovir). This indication is not well established, although it is clear
that better results can be obtained if shingles is treated initially with Acyclovir.
There are persistent reports suggesting that post-herpetic neuralgia is associated
with persistent active virus (e.g. Pavan-Langson et al, 1995). This would suggest
that antiviral treatment might be helpful.
More controversial is use of steroids during the zoster attack. While many
physicians do use steroids, there is presently no evidence supporting less neuralgia
in persons treated orally. (Calza et al, 1992). Epidural steroids have been
reported to largely prevent post-herpetic neuralgia (1.6% vs. 22.2%, comparing
epidural group to an intravenous group), but many persons might prefer not to
be treated with medications administered in this somewhat invasive way, as ones
chances are only about 1 in 5 of developing post-herpetic neuralgia.
In a trial of intrathecal steroids (given into the spinal
canal) for post-herpetic neuralgia, Kotani and others (2000) reported that 91%
of the a group with intractable post-herpetic neuralgia treated with methylprednisoline
plus lidocaine experienced good to excellent relief.
Blocks and other procedures that aim to damage nerves.
- Blocks are injections of medication intended to temporarily deaden pain nerves.
They are ordinarily done by anesthesiologists in a pain clinic.
blocks (e.g. Stellate Ganglion Block) are advocated by some anesthesiologists
as a treatment of post-herpetic neuralgia (Kageshima et al, 1992). However,
this idea is controversial , seems a bit illogical, and has not been proven
to work (Ali, 1995).
- Rhizotomy surgery means cutting of nerves. Rhizotomy may
be used to convert a neuralgia into a numbness. While effective, rhizotomy has
been replaced by several less invasive procedures.
- Radiofrequency ganglio-neurectomy
involves killing a nerve by cooking it with microwaves. It requires less cutting
than rhizotomy. It is usually used for trigeminal neuralgia. This procedure
is usually performed by pain physicians. RF can also be used successfully for occipital neuralgia.
- Gamma-knife "surgery" involves
deadening a nerve by subjecting it with gamma radiation. It requires no cutting
at all. It is usually used for trigeminal neuralgia also. This procedure may
be performed by a neurosurgeon or a radiation therapist.
A middle age woman experienced an automobile accident, and thereafter
developed severe headaches with pain behind her right ear, nose bleeds,
and loss of smell and taste. There was tenderness and wincing on
palpation of the area behind the right ear. A tentative diagnosis of
Eagles syndrome was proposed, but X-rays did not bear this out.
Diagnostic blocks of the occipital nerve abolished the pain. She
subsequently had RF-ganglioneurectomy, with complete relief of headache
for 6 months.
- Iontophoresis with calcium channel blockers has been reported to be effective
in post-herpetic neuralgia (Ikebe et al, 1995).
- Use of anti-varicella zoster
immunoglobulin has been reported to be highly successful, but this is also presumably
highly expensive. (Hugler et al, 1994)
- Nicardipine (a calcium channel blocker)
has been reported to be helpful in post-herpetic neuralgia (Farna et al, 1995).
ketamine was reported to be useful in a single patient (Hoffmann et al, 1994).
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- Hugler et al. Anaesthetist 41(12)772-8, 1992
- Ikebe H and others. Japanesr J. Anesthesiology 44: 428-33, 1995
- Kageshima et al. Jap. Jnl Anes. 41(1) 106-10, 1992
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N et al. Intrathecal methylprednisolone for intractable postherpetic neuralgia.
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A, Pasqualucci V, Galla F, De Angelis V, Marzocchi V, Colussi R, Paoletti
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- Pavan-Langston et al. Arch Ophthalmol 113(11):1381-5, 1995
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I., N. Choucair-Jaafar, et al. (2009). "beta(2)-adrenoceptors are
critical for antidepressant treatment of neuropathic pain." Ann Neurol
January 30, 2019
, Timothy C. Hain, M.D. All rights reserved.
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January 30, 2019