Ep 5. Neuropathic Pain

Diagnosing and treating neuropathic pain is very challenging. Now that you understand nociceptive pain, we’ll help you see the clear difference between that and neuropathic presentations.

Justine and Dan break down how to best treat different types of pathologies, from first line medications and navigating side effect vs benefits, through fourth line more invasive interventional options like neuromodulation, intrathecal therapies and low dose opioid options.

Making decisions around treatments is challenging and unique, and based on a lot of factors that are individual to the patient. We’ll discuss these different limitations with this type of pain and considerations you should go through so you have more effective options to consider as a patient or provider.

Introduction

Neuropathic pain is a complex type of chronic pain that can be challenging to diagnose and treat. This summary covers key points from a discussion between Dr. Dan Bates and Justine Feitelson on their podcast "It's Not in Your Head."

Characteristics of Neuropathic Pain

Neuropathic pain typically:

• Locates in the distribution of affected nerves or nerve roots

• Has a waxing and waning presentation with intermittent spikes

• Often occurs randomly without clear triggers

• Presents as burning, pins and needles, numbness, itching, crawling, painful cold, or squeezing sensations

• May include unusual symptoms like feeling water running down a limb

Unlike nociceptive pain, the specific features of neuropathic pain (e.g., burning vs. numbness) don't typically guide treatment choices.

Causes of Neuropathic Pain

Neuropathic pain can result from:

• Nerve injury (e.g., hitting your funny bone, disc protrusion compressing a nerve root)

• Nerve dysfunction

• Metabolic disturbances (e.g., B12 deficiency, diabetes)

• Infections (e.g., herpes simplex, shingles)

• Autoimmune disorders (e.g., multiple sclerosis)

• Strokes (causing post-stroke pain)

Diagnosis Challenges

Neuropathic pain is often misdiagnosed simply because healthcare providers don't ask the right questions. Patients may not volunteer information about unusual sensations for fear of sounding "crazy." Additionally, neuropathic pain can overlap with nociceptive pain, complicating diagnosis.

Emotional Impact

Neuropathic pain tends to have a stronger emotional component compared to nociceptive pain. Dr. Bates notes that neuropathic pain is more likely to make patients cry, even early in its onset. This may be due to the activation of both the "ouch" pathway and the emotional pathway in the brain.

Treatment Approaches

Treatment for neuropathic pain typically follows a stepped approach:

First-Line Medications

1. Amitriptyline (number needed to treat: 3.6)

2. Duloxetine (number needed to treat: 6.4)

3. Gabapentin

4. Pregabalin (Lyrica)

These medications are effective in only a small percentage of patients (11-25%), so managing expectations is crucial.

Topical Medications

For focal neuropathic pain, topical treatments can be effective with fewer systemic side effects.

Combination Therapy

If single medications provide partial relief, combining medications (e.g., duloxetine with pregabalin) may be more effective.

Key Takeaways for Treatment

• Start with amitriptyline for sleep disturbances

• Consider duloxetine for patients with mood issues

• Use gabapentin or pregabalin when other options are exhausted or contraindicated

• Trial medications for 4-6 weeks before switching

• Discontinue medications if side effects outweigh benefits

• Regularly reassess medication efficacy and necessity