Contents
OVERVIEW
NEUROPATHIC PAIN
- Pain arising as a consequence of a lesion or disease of the peripheral &/or central nervous system affecting the somatosensory system
- Characterized by burning, stabbing & electrical pain which may be constant, aching or paroxysmal, pins & needles
- Nerve conduction blockage causes nerve dysfunction, leading to numbness, weakness & loss of deep tendon reflexes in the area of involved nerve
- Neuropathic conditions (eg brain infarction, spinal cord trauma, ischemic neuropathies) also cause aberrant symptoms of spontaneous & provoked pain
Below is the overview of disease management of Neuropathic Pain:

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Clinical History
- History & clinical examination are required to confirm the presence of a neuropathic pain syndrome & also an important step in reaching an etiologic diagnosis for neuropathic pain
- Rapid & correct diagnosis of neuropathic pain (NP) should be done so that appropriate treatment can be started earlier
Refer to Symptoms for more information
Common Neuropathic Pain Syndromes
Central Neuropathic Pain
- Pain may be burning, shooting, aching, or pricking & is often associated with dysesthesia, hyperalgesia or allodynia to brush or cold
- Seen among post-stroke, spinal cord injury & multiple sclerosis patients
Painful Diabetic Peripheral Neuropathy (DPN)
- Symmetrical sensory loss & burning, shooting, stabbing or severe deep aching pain of both lower extremities among patients w/ diabetes mellitus (DM)
- Affects about 50% of DM patients
- Pain may be accompanied by allodynia & hyperalgesia
- Symptoms may worsen at night
Postherpetic Neuralgia (PHN)
- Pain persisting for >3 mth after herpes zoster skin lesions have healed
- Risk factors for developing PHN:
- All patients >50 yr w/ herpes zoster virus (HZV) infection
- Patients w/ a greater degree of skin surface area involved & more severe pain at presentation of HZV infection
- Patients w/ HZV ophthalmicus
- Patients who experience sensory dysfunction on the affected dermatome
- Painful prodrome prior to rash
- Patients at greatest risk for developing PHN should be offered antiviral treatment
- Diagnostic clinical features of PHN:
- Pain localized to the dermatome affected by the herpes zoster rash
- Pain may be described as burning, throbbing, sharp or shooting
- Allodynia
- Pain accompanying movement
- Areas of scarring of hypopigmentation caused by herpes zoster rash
- Presence of psychosocial stress
Trigeminal Neuralgia (TN)
- Characterized by intermittent unilateral facial pain following the unilateral sensory distribution of the trigeminal nerve, typically radiating to the maxillary or mandibular area
- Ophthalmic division pain alone occurs in <5% of patients
- Pain is quite severe, stabbing electric shock-like sensation
- Pain may be brief & paroxysmal but may occur in multiple attacks several times a day, w/ no pain between episodes
- Typically w/ normal PE findings, although mild light touch or pin perception loss has been described in the central area of the face
- Average age of pain onset in idiopathic TN is usually the 6th decade of life, but may occur at any age
- Symptomatic or secondary TN tends to occur in younger patients
- Common triggers precipitating pain attack include light touch or vibration & activities such as shaving, face washing or chewing
Postsurgical Neuropathic Pain
- Peri-incisional sensory loss, pain & allodynia for >3 mth after surgery; phantom pain following amputation or mastectomy
HIV-Related Neuropathy
- Symmetrical painful paresthesias, most prominent in the toes & soles of the feet among HIV patients
Lumbosacral Radiculopathy (Herniated Intervertebral Disc)
- Lancinating pain radiating into the anterior thigh (L2/3) or lower leg (L4-S1) w/ motor weakness or sensory loss
Complex Regional Pain Syndrome
- Regional (eg limb) pain together w/ edema, cutaneous blood flow & sweating abnormalities
Below is the overview of disease management of common neuropathic pain syndromes:

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Version: 30 Sep 2015
Guideline References:
- American Society of Pain Educators. Diabetic peripheral neuropathic pain consensus guidelines for treatment. Supplement to The Journal of Family Practice. The Journal of Family Practice. http://www.jfponline.com/home/article/diabetic-peripheral-neuropathic-pain/142bfa8d9c5e06565462f6647bfe6418.html. Jun 2006. Accessed 21 Mar 2011
- Attal N, Cruccu G, Baron R, et al. EFNS guidelines on the pharmacological treatment of neuropathic pain: 2010 revision. Eur J Neurol. 2010 Sep;17(9):1113-1123. doi: 10.1111/j.1468-1331.2010.02999.x. PMID: 20402746
- Azhary H, Farooq MU, Bhanushali M, et al. Peripheral neuropathy: differential diagnosis and management. Am Fam Physician. 2010 Apr;81(7):887-892. PMID: 20353146
- Baron R, Binder A, Wasner G. Neuropathic pain: diagnosis, pathophysiological mechanisms and treatment. Lancet Neurol. 2010 Aug;9(8):807-819. doi: 10.1016/S1474-4422(10)70143-5. Accessed 3 Mar 2014. PMID: 20650402
- Bennett MI, Attal N, Backonjan MM, et al. Using screening tools to identify neuropathic pain. Pain. 2007;127(3):199-203. Accessed 3 Mar 2014. PMID: 17182186
- Beydoun A, Backonjia MM. Mechanistic stratification of antineuralgic agents. J Pain Symptom Manage. 2003 May;25(Suppl 5):S18-S30. PMID: 12694989
- Chan A, Wong S, Chen PP, et al. Validation study of the Chinese Identification Pain Questionnaire for neuropathic pain. Hong Kong Med J. 2011 Aug;17(4):297-300. PMID: 21813898
- Chong MS, Bajwa ZH. Diagnosis and treatment of neuropathic pain. J Pain Symptom Manage. 2003 May;25(Suppl 5):S4-S11. PMID: 12694987
- Cruccu G, Sommer C, Anand P, et al. EFNS guidelines on neuropathic pain assessment: revised 2009. Eur J Neurol. 2010 Aug;17(8):1010-1018. PMID: 20298428
- Dubinsky RM, Kabbani H, El-Chami Z, et al. Practice parameter: treatment of postherpetic neuralgia: an evidence-based report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2004 Sep;63(6):959-965. PMID: 15452284
- Frykberg RG, Armstrong DG, Giurini J, et al. Diabetic foot disorders: a clinical practice guideline. American College of Foot and Ankle Surgeons. J Foot Ankle Surg. 2000;39(Suppl 5):S1-S60. PMID: 11280471
- Galluzzi K. Managing herpes zoster and postherpetic neuralgia. J Am Osteopath Assoc. 2009 Jun;109(6)(Suppl 2):S7-S12. PMID: 19553635
- Galluzzi KE. Management of neuropathic pain. J Am Osteopath Assoc. 2006 Sep(Suppl 4):S12-S18. PMID: 16273720
- Gilron I, Watson CP, Cahill CM, et al. Neuropathic pain: a practical guide for the clinician. CMAJ. 2006 Aug;175(3):265-275. PMID: 16880448
- Great Manchester Medicines Management Group. Neuropathic pain guideline. GMMMG website. http://gmmmg.nhs.uk/docs/guidance/GMMMG%20Neuropathic%20Pain%20Guidance%20March%202014.pdf. Mar 2014. Accessed 10 Jul 2015.
- Gronseth G, Alksne J, Argoff C, et al. Practice parameter: the diagnostic evaluation and treatment of trigeminal neuralgia (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology and the European Federation of Neurological Societies. Neurology. 2008 Oct;71(15):1183-1190. PMID: 18716236
- Irving GA. Contemporary assessment and management of neuropathic pain. Neurology. 2005 Jun;64(12)(Suppl 3):S21-S27. PMID: 15999405
- Jefferies K. Treatment of neuropathic pain. Semin Neurol. 2010 Sep;30(4):425-432. PMID: 20941675
- Johnson RW, McElhaney J. Postherpetic neuralgia in the elderly. Int J Clin Pract. 2009 Sep;63(9):1386-1391. PMID: 19691624
- Jovin Z, Cvijanovic M, Ilin M, et al. Assessment of neuropathic pain and clinical evaluation of patients with suspected neuropathic pain. Curr Top Neurol Psychiatr Relat Discip. 2010 Jun;18(2):30-37
- Lunsford L, Niranjan A, Young R, et al. International Radiosurgery Association: stereotactic radiosurgery for patients with intractable typical trigeminal neuralgia who have failed medical management. Radiosurgery Practice Guideline Report. 2009 Jan:001-03. http://www.irsa.org/tn%20guideline-updatedjan2009.pdf
- May S, Serpell M. Diagnosis and assessment of neuropathic pain. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2948337/. Oct 2009. Accessed 21 Mar 2011
- Moulin DE, Clark AJ, Gilron I, et al. Pharmacological management of chronic neuropathic pain - consensus statement and guidelines from the Canadian Pain Society. Pain Res Manag. 2007;12(1):13-21. PMID: 17372630
- Ping CP, Ip JW, Lam J, et al. Multidisciplinary Panel on Neuropathic Pain: recommendations for the management of postherpetic neuralgia. Medical Progress. 2006;33(10):475-482. http://www.neuropainhk.org/Portals/0/mpnp-recommendations-postherpetic-neuralgia-update-oct-2006.pdf
- Rains C, Bryson HM. Topical capsaicin. A review of its pharmacological properties and therapeutic potential in post-herpetic neuralgia, diabetic neuropathy and osteoarthritis. Drugs Aging. 1995 Oct;7(4):317-328. http://www.ncbi.nlm.nih.gov/pubmed/8535059. Accessed 15 Jul 2015. PMID: 8535059
- Taliyan R, Sharma PL. Diabetic neuropathic pain: an update and novel pharmacological strategies for relief of pain. J Med Sci. 2010;10(4):93-109
- U.S. Food and Drug Administration. Information for healthcare professionals: dangerous or even fatal skin reactions - carbamazapine. http://www.fda.gov/Drugs/DrugSafety/PostmarketdrugsafetyinformationforPatientsandProviders/ucm124718.htm. Accessed 07 Jun 2013
- Unger J. Pathogenesis, diagnosis and treatment of painful diabetic peripheral neuropathy. Applied Neurology. 2007 Feb(Suppl 1):006-15
- Várkonyi T, Putz Z, Keresztes K, et al. Current options and perspectives in the treatment of diabetic neuropathy. Curr Pharm Des. 2013;19(27):4981-5007. PMID: 23278494
- Vijayan R, Jin GK, Cardosa MS, et al. Malaysian guidelines on management of neuropathic pain. 2nd edition. Malaysian Association for the Study of Pain. www.masp.org.my. 2012. Accessed 26 Jun 2015.
- Ziegler D. Current Concepts in the management of diabetic polyneuropathy. Curr Diabetes Rev. 2011 May;7(3):208-220. PMID: 21534920