The distinct nature of neuropathic pain—caused by damage to the nerves, rather than pain elsewhere being relayed by the nerves—is reflected in the type of medication to treat it.
Medications used for epilepsy or depression may be helpful due to their effects on nerve signals, while anti-inflammatory medications—such as ibuprofen—usually are not. Opioid analgesics, sometimes called narcotics or painkillers, are an option in some cases but are not the first choice. Medication typically does not completely eliminate pain.
Finding the best medication—or combination of medications—to treat neuropathic pain often takes some trial and error. A low dose of medication is usually tried first, because side effects tend to increase with higher doses. If more pain relief is needed, the dose will typically be increased slowly. Many of these medications can take weeks to take full effect.
Anti-Epileptic Drugs (AEDs)
Medications used to control epileptic seizures are known as anticonvulsants, anti-seizure medications, or neuroleptic medications. These medications can also help calm nerve pain and are often a first-line treatment option. Anticonvulsant medications include:
- Carbamazepine (brand name Tegretol)
- Gabapentin (brand name Neurontin)
- Oxcarbazepine (brand name Oxtellar XR, and Trileptal)
- Pregabalin (brand name Lyrica)
- Topiramate, Topamax (brand name Qudexy XR, Topamax, and Trokendi XR)
Carbamazepine and oxcarbazepine are typically more useful than other medications in blocking the pain of trigeminal neuralgia. This condition in a facial nerve causes intense, sudden, short-term pain.
Side effects of anticonvulsant medications include, but are not limited to, chest pain, constipation, confusion, drowsiness, nausea, heart problems, and serious allergic reactions. Anticonvulsant medications are not advised for pregnant women.
More and more, we are learning that the same imbalances in neurotransmitters that can cause depression are also involved in chronic neuropathic pain. Moderate relief of neuropathic pain and pain-related sleep problems may be achieved with antidepressants, whether an individual has depression or not. Antidepressants reduce symptoms by fixing imbalances in the nervous system’s neurotransmitters.
The following types of antidepressants are often prescribed for neuropathic pain:
- Tricyclic antidepressants treat diabetic neuropathy, post-herpetic neuralgia (shingles), and central post-stroke pain. These medications include amitriptyline (brand names Amitril, Elavil), imipramine (brand name Tofranil), nortriptyline (brand names Aventyl, Pamelor), and desipramine (brand name Norpramin). The term tricyclic stems from the medication’s chemical structure.
- Serotonin-norepinephrine reuptake inhibitors (SNRIs) duloxetine (brand name Cymbalta) and venlafaxine (brand name Effexor) treat pain related to diabetic neuropathy. Venlafaxine extended-release is also useful in easing the pain of polyneuropathies.
- Combination therapy works well for some people. One such therapy, tapentadol (brand name Nucynta), combines elements of an antidepressant and an opioid. Studies have shown it to have some benefits over the opioid oxycodone.1,2
- Selective Serotonin Reuptake Inhibitors (SSRIs). This group of medications is not typically the first choice by itself, but may be helpful in combination with tricyclic antidepressants or if other medications are not well tolerated. Options include escitalopram (brand name Lexapro), paroxetine (brand names Brisdelle, Paxil, and others), and fluoxetine (brand names Prozac, Sarafem, and others).
Side effects and risks with antidepressants may include, but are not limited to, heart problems, constipation, drowsiness, light-headedness, weight gain, dry mouth, and nausea. Antidepressants also may increase the risk of suicidal thoughts. Women should ask their doctor before taking antidepressants or any other medication during pregnancy.
Usually available as a patch, gel, or cream, topical treatments can be helpful for localized neuropathic pain. The medication in these products is absorbed into the skin, either numbing the area or relieving pain.
Topical treatments may be a good option for individuals who cannot tolerate or prefer not to take oral medication. Little of the medication reaches the bloodstream, so cognitive side effects are avoided. Multiple applications are typically needed for significant pain relief.
Lidocaine (brand names Lidoderm, Xylocaine, and others) and capsaicin (brand names Zostrix, Trixaicin, and others) are common topical treatments.
Flushing of the face as well as swelling, burning, and other irritation in the area where the medication is applied are the most common side effects. Less common side effects include, but are not limited to, a cough, tightness in the chest/wheezing, and breathing problems.
Opioids can be helpful in certain cases, but are often discouraged because of concerns about overdoses, abuse, dependence, and the effects of long-term use. High doses of opioids typically are needed to provide significant pain relief for neuropathic conditions.
Opioids such as oxycodone (Oxecta, OxyContin), morphine (brand names MS Contin, Kadian, and others), and Tramadol (Ultra, Conzip, and others) treat diabetic peripheral neuropathy, post-herpetic neuropathy, polyneuropathy, and phantom limb pain. Phantom limb pain is pain that persists after a limb has been amputated.
Tramadol is classified by the U.S. government as a narcotic, but is a synthetic medication. It is often viewed as having a lower risk of dependence than typical opioids but may still be habit- forming.
Side effects and risks of opioids, such as drowsiness, constipation, vomiting, and nausea, cause some people to discontinue the medications. There is also a risk of life-threatening breathing problems, which can be fatal if the medication is combined with alcohol or a medication that has a sedating effect. Opioid use is not advised during pregnancy.
Other medications may be helpful in reducing the varied types of neuropathic pain. Extreme pain due to nerve irritation and inflammation can be helped with corticosteroids, such as prednisone.
See Oral Steroids
Medications for neuropathic pain may be delivered as an injection, through an implanted pain pump, or with a patch, as well as by mouth.