What are the AAN recommendations for the treatment of postherpetic neuralgia (PHN)?

Updated: Jan 25, 2019
  • Author: Camila K Janniger, MD; Chief Editor: Dirk M Elston, MD  more...
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Answer

The 2004 American Academy of Neurology (AAN) practice parameter for the treatment of postherpetic neuralgia (PHN) was last reaffirmed in 2008 and includes the following recommendations [137] :

  • Tricyclic antidepressants (TCAs) (eg, amitriptyline, nortriptyline, desipramine, and maprotiline), gabapentin, pregabalin, opioids, and topical lidocaine patches are effective in the treatment of PHN (level A, class I and II).

  • Preservative-free intrathecal methylprednisolone may be considered in the treatment of PHN if available (level A, class I and II).

  • No benefit was found with the use of acupuncture, benzydamine cream, dextromethorphan, indomethacin, epidural methylprednisolone, epidural morphine sulfate, iontophoresis of vincristine, lorazepam, vitamin E, and zimelidine (level B, class II).

  • Unproven interventions include carbamazepine, nicardipine, biperiden, chlorprothixene, ketamine, He:Ne laser irradiation, intralesional triamcinolone, cryocautery, topical piroxicam, extract of Ganoderma lucidum, dorsal root entry zone lesions, and stellate ganglion block (level U, single class II study and class IV studies).

    In 2010, the European Federation of Neurological Societies (EFNS) updated its 2005 guidelines on the pharmacological treatment of neurological pain, which included the following recommendations for the treatment of PHN [138] :

  • TCA or gabapentin/pregabalin is recommended as first-line treatment (level A).

  • Topical lidocaine (level A, less consistent results) may be considered first line in elderly patients, especially if there are concerns regarding the adverse CNS effects with oral medications.

  • Strong opioids (level A) and capsaicin cream are second-line choices.

  • Capsaicin patches show promise (level A), but the long-term effects of repeated applications, particularly on sensation, are unclear.


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