4.7.3 Neuropathic pain

General guidance

Click here to see Dudley Guidelines for the Drug Treatment of Pain in Primary Care

• Neuropathic pain (including central pain, phantom limb pain, causalgia, and reflex sympathetic dystrophy) occurs as a result of damage to neural tissue, and can generally be managed with a tricyclic antidepressant (TCA). Certain antiepileptic can be used as adjuncts to anti-depressants however specialist advice is recommended in such cases.
• Corticosteroids may be useful for compression neuropathies.
• During the acute stages of trigeminal neuralgia, carbamazepine reduces the frequency and severity of attacks. It has no effects on other forms of headache.
• Attempts at preventing the development of postherpetic neuralgia have not been particularly effective. Treatment is therefore based on managing the neuralgia once it develops. Amitriptyline may be used early in the acute phase, where this fails the addition of sodium valproate or carbamazepine may prove effective.
• Pregabalin can be used for neuropathic pain as indicated within the Dudley Pain Guidelines. It should be initiated following failure of a TCA and gabapentin.

Recommended drugs

Amitriptyline £

Gabapentin ££

Duloxetine (for painful diabetic neuropathy if amitriptyline ineffective or contraindicated) £££

Carbamazepine ££

Sodium Valproate ££

Pregabalin (prescribe as Axalid or Alzain) ££££

Drug Traffic Light Key:

Green – On Formulary

Amber – Restricted use, see local guidelines      

Purple – Specialist use/initiation

Red – Non Formulary

Relative Costs Key (where indicated):

£££££ - high

£££ - moderate

£ - low