What neuropathic pain is
Neuropathic pain arises from damage or disease affecting the somatosensory nervous system — peripheral nerves, nerve roots, dorsal root ganglia or central pathways. Unlike nociceptive pain (musculoskeletal, inflammatory), which serves a protective function, neuropathic pain results from abnormal signal generation and processing within damaged nerve fibres. The quality is characteristically burning, shooting, electric-shock-like, or tingling, often with allodynia (pain from normally non-painful stimuli such as clothing touching skin) and hyperalgesia (exaggerated pain from normally painful stimuli).
Common causes include diabetic peripheral neuropathy (distal symmetric polyneuropathy with burning feet), post-herpetic neuralgia (persistent pain after shingles), trigeminal neuralgia (brief severe facial pain triggered by light touch), chemotherapy-induced neuropathy, radiculopathy (nerve root compression from disc herniation), and carpal tunnel syndrome. Less common causes include autoimmune neuropathies, vitamin deficiency neuropathy, alcohol-related neuropathy and complex regional pain syndrome. Accurate identification of the specific cause guides targeted treatment.
- Burning, shooting or electric-shock quality different from musculoskeletal pain
- Allodynia (pain from non-painful stimuli) and hyperalgesia common
- Diabetic neuropathy, post-herpetic neuralgia, trigeminal neuralgia are frequent causes
- Central neuropathic pain from spinal cord injury or stroke also occurs
Related: Neuropathy Treatment → · Dr. Jitendra Knowledge Hub → · ICHD-3 Topic →
Treatment approaches (gabapentin, pregabalin, duloxetine)
Neuropathic pain responds poorly to standard analgesics (paracetamol, NSAIDs) and requires medications specifically targeting neuropathic mechanisms. First-line pharmacological options include gabapentin (binding voltage-gated calcium channels to reduce excitatory neurotransmitter release), pregabalin (similar mechanism with more predictable pharmacokinetics), duloxetine (serotonin-norepinephrine reuptake inhibitor enhancing descending inhibition) and amitriptyline (tricyclic antidepressant with sodium channel blockade). Selection depends on comorbidities, side-effect profile, drug interactions and patient preference.
Gabapentin and pregabalin are preferred when pain is burning and continuous, with gabapentin started low and titrated gradually to minimise sedation and dizziness. Duloxetine is preferred when pain coexists with depression or when renal impairment precludes gabapentin or pregabalin. Amitriptyline is useful for pain with sleep disturbance but must be used cautiously in elderly patients and those with cardiac disease. Topical agents (capsaicin cream, lidocaine patches) provide localised relief for post-herpetic neuralgia. Physical therapy, desensitisation techniques and psychological support complement pharmacological management. Dr. Jitendra Prasad Yadav (NMC 8029) provides individualised neuropathic pain evaluation and treatment planning at Kathmandu Neurology Clinic & Cognitive Center, Durbar Marg, Opposite of Yak & Yeti Hotel.
- Gabapentin — first-line, start low titrate slowly, sedation and dizziness common initially
- Pregabalin — similar to gabapentin, more predictable pharmacokinetics
- Duloxetine — preferred with coexisting depression or renal impairment
- Amitriptyline — useful for pain with sleep disturbance, caution in elderly
- Topical agents (capsaicin, lidocaine) for localised post-herpetic neuralgia