Neuropathic Pain

Amanda Macone, MD; James A. D. Otis, MD, FAAN, DABPM


Semin Neurol. 2018;38(6):644-653. 

In This Article

Abstract and Introduction


Neuropathic pain management is challenging, and typically requires a multifaceted approach. There are several treatment options, both pharmacologic and nonpharmacologic. Of the available pharmacologic agents, those with the strongest supporting evidence include tricyclic antidepressants, serotonin–norepinephrine reuptake inhibitors, and certain antiseizure agents. There is emerging evidence for the use of cannabinoids, but conclusive studies are not available. Nonpharmacologic therapies that have been utilized in the management of neuropathic pain include acupuncture, massage therapy, and reflexology. Despite their use as adjunctive therapies in clinical practice, the current evidence supporting their use is not strong. For the management of neuropathic pain, combination therapies are generally employed. Additional studies for emerging therapies are still needed.


Pharmacotherapy is the main tool for effective pain management in most patients. Choosing the appropriate medication requires that the pain state being treated is correctly diagnosed and classified as somatic, visceral, or neuropathic. Neuropathic pain is defined as pain secondary to a lesion or disease process involving the somatosensory system. It can be secondary to a variety of central processes such as poststroke thalamic pain, or peripheral disorders such as diabetic neuropathy. Recent reports on neuropathic pain have suggested its prevalence in the general population ranges from 5 to 8%.[1,2] While nonsteroidal anti-inflammatory drugs (NSAIDs) and opioids are considered principal medications for somatic pain, adjuvant medications such as antidepressants, antiseizure medications, anesthetics, and adrenergic agents are useful for neuropathic pain.[1] Although beyond the scope of this article, in certain patients with moderate to severe neuropathic pain, opiate agents such as tramadol, low-dose methadone, and morphine may be appropriate considerations.[3–6] Once a class of medication has been selected, the choice of a specific drug is determined by its route of administration, side effects, and individual patient characteristics. Other treatment modalities in the management of neuropathic pain include nonpharmacologic therapies and interventions, which can be considered as adjunctive agents to pharmacotherapy in appropriate patients. This article provides an overview of the nonopioid pharmacotherapy and nonpharmacologic therapies available for the management of neuropathic pain.