Consider the following special situations
Red flags
  • Diagnostic uncertainty
  • Patient has severe pain
  • Pain significantly limits daily activities
  • Underlying health condition has deteriorated
Referral to specialist care
  • Failure of medical management
  • Consideration of Qutenza and other interventions
  • Consideration of MDT assessment and management
Chronic regional pain syndrome
  • Patient information and education
  • Medication and procedures
  • Physical and vocational rehabilitation
  • Psychological intervention

Do not forget self management resources - Pain Association, Pain Concern and NHS Inform

Initial assessment

  • Neuro-anatomically plausible distribution of pain symptoms and history suggestive of relevant disease or lesion (eg. diabetes and stocking distribution of pain)
  • Altered pain sensation (eg allodynia, hyperalgesia)
  • Areas of numbness or burning
  • Continuous or intermittent evoked or spontaneous pain
  • Consider using neuropathic pain assessment tools like LANSS or PAINDETECT

1st line management

Choice depends on patient factors and physician preference

Amitriptyline

Start at 10 mg at night time increase at 10 mg increments per week up to dose with maximum benefit and least side effects

  • Maximum dose – 125 mg
Gabapentin

Start at 300 mg at night time and build up in 300 mg increments per week (through the day to make it 3 times a day ) up to a dose that gives maximum benefit with least side effects

  • Minimum effective dose – 1200mg/day
  • Maximum recommended dose – 3600 mg/day

2nd line management

Pregabalin

If amitriptyline or gabapentin is not effective or not tolerated). Start at 75 mg twice a day and build up to a dose with maximum benefit with least side effects.

  • Minimum effective dose no less than 150 mg
  • Maximum recommended dose – 600mg/day

3rd line management

Alternative Tricyclics

Nortriptyline or Imipramine in doses between 25-75mg/daily

SNRI antidepressants/Cabamazepine
  • Duloxetine 60 mg/day up to 120 mg/day
  • Carbamazepine – Start at 100-200 mg daily
  • increase by 100-200 mg increments biweekly
  • maximum of 1600mg/daily in divided doses

4th line management

Topical agents
  • Lidocaine 5% plaster can be used for localised neuropathic pain to be applied for 12 hrs and off for 12 hrs. Maximum dose – 3 patches each time
  • Capsaicin 0.075% cream could be used 3-4 times a day for 3-4 weeks

5th line management

Consider opioids but...

Please remember to wean patient off opioids if not effective.

Editorial Information

Last reviewed: 30/08/2022

Next review date: 30/08/2024

Reviewer name(s): John Muthiah.