Management of neuropathic pain

Neuropathic pain is a chronic pain condition arising from injury or disease of the peripheral or central nervous system with a substantial impact on quality of life. This brief review focuses on the increasing evidence for effective treatments and discusses an evidence-based algorithm for treating neuropathic pain conditions.

Randomized controlled trials have consistently shown efficacy of tricyclic antidepressants, gabapentin/pregabalin, opioids, tramadol, and serotonin and noradrenaline-reuptake inhibitors for the treatment of various neuropathic pain conditions, lidocaine patches for postherpetic neuralgia and cannabinoids for pain in multiple sclerosis. Carbamazepine or oxcarbazepine is the treatment of choice for trigeminal neuralgia. The efficacy of these drugs in other neuropathic pain conditions as well as the efficacy of lamotrigine and topical capsaicin is questionable, but they may be useful in a subgroup of patients.

For each patient, considerations on the underlying pain mechanisms, immediate and potential long-term side effects, and price as well as comorbidities and concurrent medications will decide which drug should be the first choice, but until further progress is made towards a mechanism-based classification, treatment is likely to be a trial-and-error process where drug combinations may also be considered.