Shingles and Chickenpox (Varicella-Zoster Virus) - Treatment for Postherpetic Neuralgia

Other Anti-Seizures Agents.Pregabalin (Lyrica) is an anti-seizure agent that has actions similar to gabapentin. Several clinical trials have reported that it is effective in reducing pain and improving sleep. However, like gabapentin, side effects can include sleepiness and dizziness. Based on current evidence, the American Academy of Neurology (AAN) has recommended pregabalin as an effective treatment for PHN. The drug was approved by the FDA at the end of 2004 and will be available in the United States in 2005. The AAN guidelines found insufficient evidence to recommend the anti-seizure medication carbamazepine (Tegretol).

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Opioids and Opioid-like Agents

Opioids. Powerful pain-killing opioid drugs may be needed in patients with severe pain that does not respond to tricyclic antidepressants. They may be delivered orally or using a patch. Oxycodone is the standard opioid for PHN. Methadone (Dolophine) may also be helpful. In one 2002 study of elderly patients, opioids were more effective than tricyclics and had fewer side effects. Although there is some concern that drug dependency may develop, studies indicate that if these narcotics are carefully monitored, they remain effective and the risk for addiction is very low. Side effects include nausea, sleepiness, and constipation.

Tramadol. Tramadol (Ultram) is a pain reliever that has been used as an alternative to opioids. It has opioid-like properties but is not as addictive. (Dependence and abuse have been reported, however.) It can cause nausea but does not cause severe gastrointestinal problems, as NSAIDs can. Studies suggest it might be very helpful for PHN patients, particularly those with heart problems or other conditions that preclude tricyclic antidepressants.

Psychologic Approaches

Stress Reduction Techniques. A panel of experts concluded that a number of relaxation and stress-reduction techniques were helpful in managing chronic pain. They include meditation, deep breathing exercises, biofeedback, and muscle relaxation. Such techniques may apply to those with severe pain from acute infection and from persistent long-term postherpetic neuralgia. [For more information, see Well-Connected Report #31, Stress.]

Behavioral Cognitive Therapy. Behavioral cognitive therapy is showing benefit in enhancing patients' beliefs in their own abilities for dealing with pain. Using specific tasks and self-observation, patients gradually shift their fixed ideas that they are helpless against the pain that dominates their lives to the perception that it is only one negative and, to a degree, a manageable experience among many positive ones. Cognitive therapy may be expensive and is often not covered by insurance. The skill of the therapist is also very important to its success.