The experience of nerve pain is described with a variety of terms: burning, hot poker, itching, tingling, lightening, shooting, electrical, and so on. In medical terms, words like hyperalgesia and allodynia are used. Hyperalgesia means that an area is overly sensitive to painful (noxious) stimuli like a pinprick. Allodynia means that an area is overly sensitive to normally non-painful (non-noxious) stimuli like light touch. Both of these phenomena are hallmarks for nerve pain.
Many common ailments cause nerve pain. The most recognizable cause of nerve pain is diabetic peripheral neuropathy. The nerve damage caused by abnormal blood sugar levels cause the nerve to dieback in a “stocking and glove” distribution. First, the area of the foot and ankle region (stocking area) is usually affected with numbness and tingling. As the neuropathy progresses, burning pain will begin as well. Diabetic peripheral neuropathy is a classic example of nerve pain that is generated in the periphery-in the outer most nerve branches. Other types of nerve pain are generated centrally. Examples of centrally mediated nerve pain include many of the pain syndromes like Fibromyalgia Syndrome. Fortunately, both types of nerve pain, peripheral and central, respond to the same types of medications.
Anti-depressants like amitriptyline (Elavil), imipramine, and desipramine can all be very useful for nerve pain. When taken at bedtime, these drugs can also improve sleep. Cymbalta is the newest anti-depressant used to treat painful conditions. However, not all antidepressants work for nerve pain. Medications like Prozac and Paxil do not consistently help reduce pain. Furthermore, the anti-depressants can cause intolerable side effects like: drowsiness, urinary retention, dizziness, dry mouth, and confusion. These side effects are especially common and devastating in the elderly population. For that reason, a doctor might consider prescribing these medications in topical compounded formulas. Compounded topical preparations are effective for nerve pain without the severe side effects (but, they can be cost prohibitive also).
Anti-convulsants like gabapentin, zonisamide, tiagabine, and pregabalin (Lyrica) are all very useful to treat nerve pain. Just like they calm the nerves down to prevent seizures, this class of medications calm down the nerves to reduce nerve generated pain impulses. But again, the side effects to these medications can be intolerable especially in the elderly. But yet again, these drugs can also be applied topically in a compounded formulation. When used in combination, anti-convulsants and anti-depressants can be the one-two punch that is needed to knock nerve pain down a couple notches.
Other medications are also worth mentioning for the treatment of nerve pain. Tramadol (Ultram) is greatly underappreciated for its ability to treat nerve pain. Both the short acting form and the extended release form are very effective at reducing the burn of a nerve on fire. Side effects to tramadol are usually minimal but can include nausea, drowsiness, and headache. Another useful medication is topical lidocaine which comes in transdermal patches or gels that are applied to the skin. Lidocaine needs to be used cautiously and as directed because it can affect the heart. Finally, the heavy hitter, methadone, is very useful for treating nerve pain. For more information about methadone see “The Five Frequently Asked Questions About Methadone.”
Methadone deserves special attention and care. Other medications are used for nerve pain in innovative ways that are usually “off label”. Creative care is paramount for nerve pain which can be tricky to treat.
Nerve pain due to peripheral neuropathy or a central pain syndrome can be an unrelenting hot-poker, torture experience. In my experience, using a combination of medications at small doses is more effective than mono-therapy (a one drug, one problem approach). Sometimes it takes trial and error to find the right combination. At times, patients feel like guinea pigs. With patience and perseverance, a doctor can usually find the right combination of medications that douses the fire of nerve pain.
_For those interested in reading my attempt at creatively describing nerve pain, please see my poem _“My Nerve’s On Fire”.