Postherpetic neuralgia

Postherpetic neuralgia is a nerve pain that occurs at the site of a previous attack of shingles. Neuralgia is a term that describes nerve pain.

Information written and reviewed by Certified Doctors.

Contents

Key Information

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What should I do?

If you think you have this condition you should see a doctor within 2 weeks.

How is it diagnosed?

Your doctor might diagnose postherpetic neuralgia based on your symptoms and physical examination findings.

What is the treatment?

Postherpetic neuralgia does not typically respond to non-prescription painkillers. However, the following may help to relieve the pain:

  • certain antidepressant and antiepileptic medications, prescribed by your doctor
  • Lidocaine plasters or capsaicin creams, applied to the affected areas cold packs
  • wearing comfortable clothing
  • covering the affected areas.

Introduction

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Postherpetic neuralgia is a nerve pain that occurs at the site of a previous attack of a condition called shingles. Neuralgia is a term that describes nerve pain.

What causes postherpetic neuralgia?

Postherpetic neuralgia is nerve pain which continues 3-6 months after the shingles rash has healed.

Shingles is a condition caused by re-activation of the varicella-zoster virus, which lies dormant (inactive) in the nerves following a chickenpox infection. The virus becomes active in two or three nerve roots and causes a flu-like illness. In most cases, the rash and pain of shingles lasts two to four weeks.

Read more about the causes of postherpetic neuralgia.

Seeing your doctor

The pain of postherpetic neuralgia may be intense and can take the form of:

  • burning
  • stabbing
  • aching
  • itching
  • an ‘electric shock’
  • hyper-sensitivity of the skin in the affected area (allodynia)

Read more about the symptoms of postherpetic neuralgia.

It is important to revisit your doctor if you continue to have pain for more than two or three months after having shingles. The earlier the diagnosis is made, the greater the chance of relieving the pain of postherpetic neuralgia.

Postherpetic neuralgia is easy to diagnose because it only occurs as a complication of shingles, and the pain will be in the area of the body supplied by the affected nerves.

If you have had shingles, your doctor can diagnose postherpetic neuralgia based on your symptoms and the length of time you have had them.

Who is affected?

Approximately 10-20% of people with shingles will go on to develop postherpetic neuralgia. The risk of developing postherpetic neuralgia increases with age. It is more common in people over 60 and affects one-third of people over 80.

Treating postherpetic neuralgia

Many people with postherpetic neuralgia make a full recovery within a year of developing the condition. But occasionally, the nerves do not heal completely and symptoms last for several years or permanently.

Treatments can ease the symptoms of postherpetic neuralgia, although they may not relieve the pain completely.

Most people respond to medication, such as tricyclic antidepressants, anti-epileptic or opioid pain medication, which can be prescribed to reduce the pain.

Read more information about how postherpetic neuralgia is treated.

About 40-50% of people with postherpetic neuralgia do not completely respond to any form of treatment.

A vaccine is available for people over 50 to boost immunity and prevent reactivation of the virus. This has been shown to reduce considerably the likelihood of getting shingles for at least five years. It may need to be repeated for lasting immunity.

Living with long-term pain

Living with postherpetic neuralgia can be very difficult. Postherpetic neuralgia can interfere with your ability to carry out certain daily activities, such as dressing and bathing. You may also have problems sleeping and feel tired (mental or physical tiredness) which can lead to stress and anxiety.

Living with pain, particularly if it affects your quality of life, can also lead to depression (feelings of extreme sadness or despair that last for a long time).

Symptoms

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The main symptom of postherpetic neuralgia is continuous nerve pain in an area previously affected by shingles.

The pain has been described as burning, stabbing, shooting, aching or throbbing. There may also be itching in the affected area that is sometimes referred to as ‘postherpetic itch’.

Other symptoms are described below.

Increased sensitivity of the skin

The areas previously affected by shingles may become more sensitive (hyperaesthesia) or sensitivity may be reduced.

If sensitivity is reduced you may feel numbness, which may be unpleasant (dysaesthesia).

Allodynia

Allodynia is where someone experiences pain from things that would not usually cause pain, such as:

  • combing hair
  • getting dressed
  • heat
  • a cold draught
  • a light touch

Seeing your doctor

Postherpetic neuralgia is an easy condition to diagnose because it only occurs as a complication of shingles, and the pain will be in the area of the body supplied by the affected nerves.

If you have had shingles, your doctor can diagnose postherpetic neuralgia based on your symptoms and the length of time you have had them.

It is important to revisit your doctor if you continue to have pain for more than two or three months after having shingles. The earlier the diagnosis is made, the greater the chance of relieving the pain of postherpetic neuralgia.

Causes

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Postherpetic neuralgia is the most common complication of shingles. It is not clear why some people who have shingles go on to develop postherpetic neuralgia, but having a severe rash that takes a long time to heal may be a risk factor.

The varicella zoster virus (the virus that causes chickenpox and shingles) causes nerve damage and an imbalance between large and small fibres in the affected nerves. This alters chemicals that are released in the spinal cord and the higher connections in the brain.

The brain may respond by altering the processing of the messages it receives and signals it sends to the damaged nerves. This may cause and prolong the pain.

Increased risk

Risk factors known to increase the likelihood of developing postherpetic neuralgia include:

  • age – the condition is more common in people who are over 60 years old
  • a weakened immune system (the body’s natural defence system)
  • a more severe rash during shingles
  • pain in an area of skin before the rash appears

You may also be at an increased risk of developing postherpetic neuralgia if a previous attack of shingles affected your chest or the nerve to your face.

Treatment

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There are several types of medication used to treat the symptoms of postherpetic neuralgia. You may need to try different medications before you find a combination suitable for you.

If you have postherpetic neuralgia, you can try a number of things which may help reduce the painful symptoms of the condition.

Some measures you can take to reduce pain are described below.

  • Wear comfortable clothing – clothes that are too tight or made of rough or synthetic material may irritate your skin and make your symptoms worse. Wearing cotton clothing will usually cause less irritation.
  • Cover sensitive areas – you may find some areas of your skin are more affected by postherpetic neuralgia than others. If your clothes tend to rub in certain areas, try covering them with a plastic wound dressing or cling film.
  • Use cold packs – unless your postherpetic neuralgia is made worse by cold, you could try using gel-filled cold packs to numb the pain. Simply place the pack in the freezer to cool it down before placing it gently against your skin.

Neuropathic pain does not respond well to ordinary painkillers, such as aspirin, paracetamol and ibuprofen. A stronger painkiller, such as codeine or tramadol, may be prescribed.

Other medications can also be used to help ease and manage the pain such as tricyclic medications, anti-epileptic medication such as gabapentin, and opioid pain medications such as morphine.

Things to consider

There are a number of things to consider when trying different treatments, such as:

  • why the medication is being offered
  • the benefits of the medication
  • potential side effects of the medication, such as drowsiness, poor concentration and loss of balance
  • how the medication could potentially affect day-to-day life
  • the preferred medication of the person with neuropathic pain
  • whether you are taking any other medications
  • any physical or mental health problems that you are experiencing

Initial treatments

Two main treatments are recommended for treating neuropathic pain such as postherpetic neuralgia. These medications are:

  • amitriptyline
  • pregabalin

If you are already taking a medication to manage your neuropathic pain, you should be able to continue taking this while starting a new form of treatment.

Amitriptyline and pregabalin may help reduce your pain significantly, but they might not ease it completely.

Amitriptyline

Amitriptyline is a tricyclic antidepressant shown to be effective at treating neuropathic pain as well as depression. It works by affecting chemicals in your brain and the spinal cord that react to pain, and can make them less sensitive.

Doses of amitriptyline start low and build up over a few weeks depending on the benefits and side effects. It may take up to 2-3 weeks to feel the full effects as the correct dose is reached.

Common side effects of amitriptyline include:

  • dry mouth
  • sweating
  • problems passing urine
  • slight blurring of vision
  • drowsiness

Due to the drowsiness caused by amitriptyline, you should not drive until you are on a stable dose that does not cause drowsiness and poor concentration.

If you are prescribed amitriptyline and your painful symptoms are reduced but you cannot tolerate the side effects, you may be offered an alternative antidepressant such as:

  • imipramine
  • nortriptyline

Pregabalin

Pregabalin is an anti-epileptic (anticonvulsant) medication used to treat epilepsy. Like amitriptyline, it is also effective in helping people with neuropathic pain. It works by helping ‘damp down’ nerve impulses.

Both amitriptyline and pregabalin can be taken as tablets or in the form of a syrup. You will be started on a low dose, which will be gradually increased over time. It may be a number of weeks before you start to feel the benefits.

Dizziness and drowsiness are the two most common side effects of pregabalin. Therefore, do not drive or operate heavy machinery if you have these side effects. Other side effects of pregabalin may include:

  • lack of co-ordination
  • weight gain
  • fluid retention
  • temporary memory impairment

Alternative treatments

If the medication you are taking is not effective in managing your neuropathic pain, you may be prescribed alternative treatments and referred to a specialist pain clinic to help manage your pain.

While you are waiting to be referred to a pain clinic you may be prescribed:

  • tramadol
  • lidocaine patches

Tramadol belongs to a group of medicines called opioids. It is an effective painkiller that can help to treat neuropathic pain.

Common side effects of tramadol can include:

  • nausea (feeling sick)
  • dizziness
  • constipation
  • sweating
  • dry mouth
  • confusion
  • headache
  • vomiting

Like all opioids, tramadol can be addictive if taken over long periods of time, so it should be prescribed for the shortest time possible.

If you cannot take tablets or syrup for medical reasons, your doctor may offer you a treatment called lidocaine patches.

A lidocaine patch can provide pain relief without many side effects. It can also be used in combination with other treatments.

Lidocaine plasters contain a local anaesthetic, which has a painkilling effect on the area where the plaster is applied. Make sure you follow the instructions that come with the lidocaine plasters when applying them to your skin.

Other types of opioids, such as morphine or oxycodone, may be offered as a treatment for neuropathic pain, although in some cases you may need to be assessed in a specialist pain clinic. Your doctor can continue to prescribe medications that have been recommended by pain specialists.

Complementary therapies

Some people find using complementary therapies alongside regular treatment can help them manage pain, stress and anxiety.

Complementary therapies include:

  • meditation and other relaxation techniques
  • massage
  • acupuncture
  • vitamin therapy

However, there is currently no clinical evidence for the effectiveness of these treatments.

You could also try relaxing activities, such as listening to soothing music and taking warm baths.

Assessment

While you are being treated for neuropathic pain, your progress will be regularly reviewed to assess how effectively you are responding. In each review, the following will be assessed and taken into consideration:

  • how much your neuropathic pain has been reduced
  • whether you are having adverse side effects from the medication

Depending on the outcome of your reviews, your medication may be changed or the dosage may be altered.

Content supplied by NHS Choices