Synopsis
Diagnose pain caused by a somatosensory lesion, identify urgent compressive and treatment-related causes, combine cause-directed care with a cautious adjuvant trial, and judge success by function and tolerability rather than complete symptom abolition.
- Diagnose neuropathic pain only when characteristic symptoms and sensory signs fit a plausible lesion or disease of the somatosensory system.
- First-line examination maps light touch, pinprick, temperature, allodynia, reflexes, power and gait and checks urgently for cord, root or plexus compromise.
- Treat the cause when possible: decompression, radiotherapy, diabetes control, vitamin replacement, antiviral treatment or modification of a neurotoxic medicine may preserve function.
- NICE initial non-trigeminal options are amitriptyline, duloxetine, gabapentin or pregabalin, selected by comorbidity, interactions, renal function, misuse risk and patient preference.
- Start one medicine low, titrate gradually, set a functional goal and allow an adequate trial at a tolerated dose before switching.
- If the first option fails or is not tolerated, offer one of the remaining choices rather than layering multiple sedatives immediately.
- Capsaicin cream is an option for localised neuropathic pain when oral medicines are unsuitable or not wanted; high-concentration patch use is specialist.
- Tramadol should be considered only as short-term rescue in this pathway, not routine long-term treatment, because of dependence, seizure and serotonin risks.
- There is no single gold-standard medicine. The benchmark is improved sleep or function with tolerable harm, reviewed alongside cause and rehabilitation.
Key red flags
Back or radicular pain with new motor, sensory, gait or bladder or bowel change requires emergency MSCC or cauda-equina assessment.
Rapidly progressive, asymmetric or proximal neuropathy may indicate plexopathy, vasculitis, infection, leptomeningeal disease or treatment toxicity needing specialist investigation.
A hot, swollen, colour-changing limb with allodynia after procedure requires evaluation for infection, thrombosis and complex regional pain syndrome.
New confusion, falls or respiratory slowing after gabapentinoid addition to an opioid is medication toxicity until reviewed.
Gabapentin and pregabalin require renal adjustment and gradual withdrawal; abrupt cessation after sustained use can cause severe symptoms or seizures.
Active suicidal thinking, marked mood change, misuse or escalating unsanctioned doses requires same-day mental-health and medicine-safety assessment.
Pain with new weakness, gait decline, saddle loss or sphincter dysfunction requires urgent structural imaging and specialist care.
Investigation priorities
Map distribution, positive and negative symptoms, onset, progression, triggers, functional loss and temporal relation to cancer or treatment.
Management branches
Non-trigeminal neuropathic pain is diagnosed and no neurological emergency requires immediate intervention.
- Identify and treat the cause, define a sleep or function goal and review renal, hepatic, cardiac, falls, mood, interaction and misuse risks.
- Choose amitriptyline, duloxetine, gabapentin or pregabalin, start at a tolerable dose and provide titration, driving and withdrawal information.
- Review after each increase and after an adequate trial; continue for meaningful benefit, taper and switch for failure or harm and avoid abrupt gabapentinoid cessation.