Neuropathic Pain — Assessment & Management

The full reasoning pathway — confirm the pain is neuropathic, treat any underlying cause, follow the NICE first-line drug ladder (escalating one agent at a time), add non-drug measures, and safety-net.StartDecisionInvestigateActionReferStop / Admit

PresentationNeuropathic pain

Burning, shooting, electric pain in a neuroanatomical distribution; allodynia. Identify the cause (diabetes, post-herpetic, radiculopathy, post-surgical).

Step 1 · Safety — sinister causeSinister underlying cause?

Progressive deficit, cord/cauda equina features, cancer history, systemic illness → investigate/refer rather than just analgesia.

YES

Stop · EscalateInvestigate cause

Image / refer per red flag; don't mask a compressive or malignant lesion.

Treat causeOptimise the driver

Glycaemic control in diabetic neuropathy; manage radiculopathy; antivirals window in shingles.

Step 7 · NICE drug ladder (CG173)

Step 7 · ActionFirst-line monotherapy

Offer a choice of amitriptyline, duloxetine, gabapentin or pregabalin; switch if ineffective/not tolerated (try alternatives in turn). Tramadol only for acute rescue; topical capsaicin for localised pain. Avoid routine strong opioids.

ReferEscalation

Pain clinic pain uncontrolled despite first-line agents. Specific syndromes: trigeminal neuralgia → carbamazepine + neurology.

Step 8 · non-drug & self-management

Step 8 · Non-drug & self-managementTreat the whole person

Treat the driver (glycaemic control, etc.) and support function: graded exercise/physiotherapy, sleep and pacing, psychological therapy (CBT/ACT) for distress, TENS/acupuncture as adjuncts. Set realistic goals (function, not zero pain). For chronic primary pain (NG193) emphasise exercise/CBT and an antidepressant rather than analgesics/gabapentinoids.

Step 9 · review & safety-net

Step 9 · Review & safety-netTitrate, deprescribe, escalate

Review each drug at an adequate dose/duration before switching (sequential monotherapy); taper and stop ineffective agents (incl. gabapentinoids — misuse/dependence risk). Urgent if progressive weakness, new bladder/bowel or saddle symptoms (cord/cauda equina), or systemic/red-flag features — investigate rather than just escalating analgesia.

⚠️ One agent at a time: the NICE approach is sequential monotherapy — switch rather than stacking — and strong opioids have a limited role. For chronic primary pain (NG193) — no clear cause / impact disproportionate (e.g. fibromyalgia, CRPS): do NOT start opioids, NSAIDs, paracetamol, gabapentinoids, antiepileptics, antipsychotics or benzodiazepines; offer exercise, CBT/ACT, acupuncture, or an antidepressant (off-label) — even without depression.

ronic neuropathic pain.

Done

Safety

Red Flags — Exclude Compressive & Sinister Causes First

Neuropathic pain is a symptom, not a diagnosis. Before reaching for the NICE NG173 ladder, exclude the emergencies and the malignant causes that demand urgent imaging or referral.

Cauda equina syndrome Bilateral sciatica, saddle anaesthesia, bladder/bowel dysfunction, sexual dysfunction → 999 / emergency MRI. Time-critical.

Metastatic spinal cord compression (MSCC) Known/suspected cancer + new severe or progressive back pain, band-like pain, limb weakness, sensory level → MSCC pathway: MRI whole spine within 24h + oncology (NICE NG12 / CG75).

Progressive neurological deficit Rapidly worsening weakness, ascending sensory loss → urgent neurology (exclude GBS, cord lesion).

New mononeuritis multiplex Multiple named-nerve deficits → urgent workup for vasculitis/diabetes — needs specialist input.

Herpes zoster (acute) Dermatomal pain + vesicles → antivirals within 72h; ophthalmic/otic involvement → same-day ophthalmology/ENT.

Infection / systemic features Fever, weight loss, IV drug use with spinal pain → exclude discitis/epidural abscess urgently.

NG173 explicitly assumes serious underlying pathology has been excluded. Cauda equina and metastatic spinal cord compression are the two great misses in a patient presenting with new neuropathic limb pain — both are time-critical and both are tested. In any patient with a cancer history, new or progressive back/radicular pain is MSCC until proven otherwise.

Done

Diagnose

Confirm Pain is Neuropathic

Distinguish neuropathic from nociceptive pain — it changes the entire treatment approach. Standard analgesics largely do not work.

Descriptors

Burning, shooting, electric-shock, stabbing, tingling, “pins and needles”. Often worse at night.

Sensory features

Allodynia (pain from non-painful stimuli e.g. clothing), hyperalgesia, numbness, paraesthesiae in a neuroanatomical distribution.

Screening tools

DN4, LANSS or painDETECT support (not replace) clinical judgement in identifying a neuropathic component.

Common causes

Diabetic painful neuropathy, post-herpetic neuralgia, trigeminal neuralgia, sciatica/radiculopathy, post-surgical/traumatic nerve injury, central pain (post-stroke, MS), chemotherapy-induced.

Mixed pain

Many conditions (e.g. low back pain, cancer pain) have mixed nociceptive + neuropathic components needing combined approaches.

Impact

Assess sleep, mood, function and the meaning of pain — chronic neuropathic pain is strongly linked with depression and disability.

Neuropathic pain arises from a lesion or disease of the somatosensory system and responds poorly to paracetamol, NSAIDs and (largely) opioids. Recognising the characteristic descriptors and signs (allodynia, dermatomal/neuroanatomical distribution) directs treatment to the agents proven effective in NG173.

Done

Diagnose

Examination & Targeted Investigation

Examination localises the lesion and screens for treatable causes; investigations are guided by the suspected aetiology, not routine.

Neurological exam

Power, tone, reflexes, sensory modalities (light touch, pinprick, vibration, proprioception), gait. Map deficit to nerve/root/central pattern.

Diabetic foot check

Monofilament, vibration, foot inspection — diabetic neuropathy is the commonest cause; assess ulcer risk.

Skin

Zoster scarring (post-herpetic neuralgia), trophic changes, signs of CRPS (swelling, colour/temperature change).

Bloods (by cause)

HbA1c/glucose, B12 + folate, U&E, LFTs, TFTs, FBC; consider ESR/immunoglobulins, HIV, autoantibodies if atypical/progressive.

Imaging

MRI spine for radiculopathy with red flags or failure to settle; urgent if cord/cauda equina/MSCC suspected.

Specialist tests

Nerve conduction studies/EMG via neurology for diagnostic uncertainty or progressive/asymmetrical neuropathy.

The examination confirms the neuroanatomical basis of the pain and identifies reversible contributors — especially diabetes and B12 deficiency. Routine imaging and neurophysiology are unnecessary for typical, stable presentations but become essential when red flags, progression, or diagnostic uncertainty are present.

Done

Treat

First-Line Pharmacotherapy (NICE NG173)

For all neuropathic pain except trigeminal neuralgia, offer a choice of one of four first-line agents. Treat the underlying cause in parallel.

Choose 1 of 4Amitriptyline, duloxetine, gabapentin OR pregabalin as initial first-line monotherapy (NG173). Choice is guided by comorbidity, side effects, cost, risk of misuse and patient preference.

AmitriptylineStart 10 mg ON, titrate to 75 mg ON as tolerated. Useful where sleep disturbance coexists. Cautions: anticholinergic effects, QTc, falls in elderly.

DuloxetineFirst-line of choice in painful diabetic neuropathy. Start 30 mg → 60 mg OD. Caution: nausea, BP, interactions.

Gabapentin / PregabalinTitrate gabapentin from 300 mg; pregabalin from 75 mg BD. Note Class C controlled-drug status and misuse/diversion risk; counsel and review. Reduce dose in renal impairment.

If first drug failsSwitch to one of the remaining three (try sequentially). Titrate to effect/tolerability before judging failure.

NG173 (2019, updated) recommends a choice of amitriptyline, duloxetine, gabapentin or pregabalin as first-line for neuropathic pain (other than trigeminal neuralgia), and to switch — not stack — if the first is ineffective or not tolerated. Pregabalin and gabapentin are Schedule 3 controlled drugs in the UK; misuse potential must be considered when prescribing.

Done

Treat

Escalation, Combination & Specific Therapies

If sequential monotherapy fails, consider combination, topical agents, and condition-specific treatments — but avoid the agents NG173 advises against.

Combination

Consider combining agents from different classes (e.g. amitriptyline + gabapentinoid) under review, balancing benefit vs side-effect burden.

Topical capsaicin

Capsaicin 0.075% cream for localised pain; 8% patch (specialist) for localised post-herpetic neuralgia in those who cannot take oral drugs.

Trigeminal neuralgia

Carbamazepine is first-line (NG173). Refer to specialist/neurology if it fails or diagnosis uncertain (exclude MS, mass lesion).

Tramadol

Only as acute rescue, short-term — not for long-term neuropathic pain.

Avoid (NG173)

Do NOT start morphine and other strong opioids, cannabis-based products, or (except by specialists) other antiepileptics for neuropathic pain in non-specialist settings.

Acute zoster

Antivirals within 72h reduce post-herpetic neuralgia risk; treat established PHN as neuropathic pain.

NG173 specifically advises against initiating strong opioids, cannabis-based medicinal products, and most other antiepileptics outside specialist care, because of poor efficacy and significant harms in chronic neuropathic pain. Carbamazepine remains the distinct first-line treatment for trigeminal neuralgia, reflecting its specific evidence base.

Done

Refer

Referral Pathways

Refer for red flags, diagnostic uncertainty, refractory pain, or when specialist-only treatments are being considered.

Emergency

Suspected cauda equina, MSCC, epidural abscess, or rapidly progressive deficit — same-day imaging/admission.

Urgent oncology / MSCC

Cancer patient with new/progressive spinal or radicular pain — MSCC coordinator + whole-spine MRI within 24h.

Neurology

Diagnostic uncertainty, progressive/atypical neuropathy, trigeminal neuralgia failing carbamazepine, suspected central cause/MS.

Pain clinic

Refractory pain despite optimised treatment; for interventional options, combination regimens, and multidisciplinary support.

Diabetes / specialist medicine

Painful diabetic neuropathy not responding to optimised glycaemia + first-line agents.

Primary care manage

Typical, stable neuropathic pain responding to NG173 first-line therapy with adequate review.

Most neuropathic pain is managed in primary care, but the referral filter must reliably catch the compressive emergencies and the cancer-related pain, and route refractory or specialist-treatment cases appropriately. Early pain-clinic involvement helps patients with persistent pain avoid escalating, low-value drug regimens.

Done

Lifestyle

Self-Management & Non-Pharmacological Care

Education & expectations Explain neuropathic pain and that the goal is meaningful reduction and improved function, not always abolition of pain.

Psychological therapy CBT/ACT reduces pain-related distress, catastrophising and disability; refer pain psychology for persistent pain.

Physical activity Graded exercise and physiotherapy maintain function and mood; pacing strategies for flares.

Sleep & mood Treat coexisting insomnia and depression — bidirectional relationship with pain. Choice of agent (e.g. amitriptyline, duloxetine) can address both.

TENS & self-help TENS may help some; signpost to self-management resources and pain support groups.

Foot & skin care In sensory neuropathy, protect insensate areas; diabetic foot surveillance to prevent ulceration.

Chronic neuropathic pain is best managed with a biopsychosocial approach; drugs alone rarely suffice. CBT/ACT, graded activity and addressing sleep and mood improve function and reduce reliance on escalating medication, consistent with the NICE chronic pain guidance (NG193) emphasis on supported self-management.

Done

Treat

Prescribing Safety & Review

Titrate & review

Start low, go slow; review efficacy and side effects at 4–6 weeks (drugs take weeks to work). Stop ineffective drugs rather than layering.

Gabapentinoid stewardship

Class C controlled drugs — assess misuse risk, avoid co-prescribing with opioids where possible (respiratory depression deaths), counsel on driving and dependence.

Renal/hepatic dosing

Reduce gabapentin/pregabalin in renal impairment; caution with duloxetine in hepatic impairment.

Pregnancy

Review all agents in pregnancy/planning — seek specialist advice; many have safety concerns.

Elderly

Falls, sedation, anticholinergic load (amitriptyline) — use lowest effective dose, review regularly.

Deprescribe

If no benefit, taper and stop; avoid indefinite continuation of ineffective therapy.

Safe prescribing is a core SCA competency: gabapentinoids carry real dependence and overdose risk (especially with opioids), tricyclics cause falls and anticholinergic harm in older people, and any agent should be stopped if it does not deliver meaningful benefit after an adequate, titrated trial.

Done

Safety

Follow-Up & Safety-Netting

4–6 weeks

Review response to first-line agent; titrate or switch per NG173. Reassess sleep, mood and function, not just pain score.

Ongoing

Monitor side effects, adherence, and (gabapentinoids) signs of misuse; review the underlying cause (e.g. glycaemic control).

Re-examine

Repeat neurological assessment if symptoms change — new or progressing deficit warrants re-triage for compressive/sinister cause.

Safety-net — 999/urgent

New bladder/bowel disturbance, saddle anaesthesia, bilateral leg weakness, or rapidly progressive deficit → emergency (cauda equina/cord compression).

Safety-net — cancer

Known cancer with new/worsening spinal or band-like pain → urgent MSCC pathway.

Refractory

Persistent disabling pain despite optimised therapy → pain clinic + psychological support.

A neuropathic-pain label must not anchor future assessments: a change in neurological signs always reopens the question of a compressive or malignant cause. Structured review at 4–6 weeks prevents both premature abandonment of effective drugs and indefinite continuation of ineffective ones.