Management Of Post-Herpetic Neuralgia

A 56-year-old woman comes for review. Around 4 weeks ago she had a blistering rash under her right breast which extended around to the back. A diagnosis of shingles was made. Unfortunately since that time she has been experiencing severe 'shooting' pains. The skin is also very tender to touch. Neither paracetamol nor ibuprofen have helped her symptoms. What is the most appropriate next step in management?
A. Lidocaine patch
B. Tramadol
C. Amitriptyline
D. Carbamazepine
E. Diclofenac

Answer:
C. Amitriptyline

Discussion: This lady has developed post-herpetic neuralgia. NICE recommend using amitriptyline, duloxetine, gabapentin or pregabalin first-line.

Neuropathic pain: may be defined as pain which arises following damage or disruption of the nervous system. It is often difficult to treat and responds poorly to standard analgesia.
Examples include:
 diabetic neuropathy
 post-herpetic neuralgia
 trigeminal neuralgia
 prolapsed intervertebral disc

NICE updated their guidance on the management of neuropathic pain in 2013:

 first-line treatment : amitriptyline, duloxetine, gabapentin or pregabalin
 if the first-line drug treatment does not work try one of the other 3 drugs
 tramadol may be used as 'rescue therapy' for exacerbations of neuropathic pain
 topical capsaicin may be used for localised neuropathic pain (e.g. post-herpetic neuralgia)
 pain management clinics may be useful in patients with resistant problems

*please note that for some specific conditions the guidance may vary. For example carbamazepine is used first-line for trigeminal neuralgia