Understanding Neuropathic Pain: When Nerves Are the Problem

Neuropathic pain is one of the most challenging categories of chronic pain — and one that frequently goes undertreated because it requires different approaches than the musculoskeletal or inflammatory pain most people are more familiar with.

If your pain is described as burning, shooting, stabbing, electric-quality, or accompanied by unusual skin sensations (allodynia — pain from light touch; hyperalgesia — exaggerated pain response), you likely have a neuropathic component that needs targeted treatment.

What Makes Neuropathic Pain Different?

Neuropathic pain arises from damage or dysfunction in the nervous system itself — peripheral nerves, spinal cord, or brain — rather than from tissue injury or inflammation. The damaged nervous system sends abnormal pain signals that don't correspond to actual tissue damage.

This is why neuropathic pain:

• Often persists long after the original injury or condition has "healed"
• Doesn't respond well to anti-inflammatory medications or opioids
• Has that distinctive burning, electric quality
• May be accompanied by hypersensitivity (light touch is painful)
• Requires specifically targeted neuropathic agents

Common Causes

• Diabetic peripheral neuropathy (DPN)
• Post-herpetic neuralgia (shingles pain)
• CRPS (Complex Regional Pain Syndrome)
• Radiculopathy (nerve root compression)
• Chemotherapy-induced peripheral neuropathy
• Post-surgical nerve injury
• HIV-associated neuropathy
• Small fiber neuropathy (often underdiagnosed)

Treatment Approaches

First-line medications:

• Duloxetine (Cymbalta) or pregabalin (Lyrica) — recommended first-line by multiple guidelines
• Gabapentin — very commonly used; best evidence at higher doses
• Tricyclic antidepressants (amitriptyline, nortriptyline) — effective, particularly for post-herpetic neuralgia
• Topical lidocaine or capsaicin patches — useful for focal neuropathic pain

Low Dose Naltrexone: LDN's microglial-inhibiting mechanism targets neuroinflammation that contributes to many neuropathic pain conditions. I use LDN frequently as an adjunct in neuropathic pain.

Interventional approaches:

• Sympathetic nerve blocks (for CRPS and sympathetically maintained pain)
• Spinal cord stimulation (for refractory neuropathic pain, diabetic neuropathy, CRPS)
• Intrathecal drug delivery (for severe, refractory neuropathic pain)

What typically doesn't help:

• Opioids (limited efficacy in neuropathic pain and often worsen central sensitization)
• NSAIDs (anti-inflammatory mechanism not relevant to neuropathic pain)
• Muscle relaxants

Getting the Right Diagnosis

The key to treating neuropathic pain is identifying the specific type and cause. A comprehensive neurological evaluation — including assessment of nerve function, imaging to identify structural causes, and sometimes nerve conduction studies — is essential.

If you have unexplained burning, shooting, or electric pain, call 516-492-3100 to discuss evaluation and treatment options.