Neuropathic Pain (29)
Pain originating in the face, or elsewhere, may be caused by an injury, an infection in a structure of the face, a nerve disorder, or it may occur for no known reason.
Some common causes of facial pain include:
Abscessed tooth (a condition in which a tooth is surrounded by inflammation and pus)
Sinusitis (inflammation of the sinuses)
Injury to the face
TMJ disorders (TMJ stands for temporomandibular joint, or the jaw joint)
Trigeminal neuralgia (described below)
What Is Trigeminal Neuralgia?
Trigeminal neuralgia (TN), also called tic douloureux, is a condition that is characterized by intermittent, shooting pain in the face.
Trigeminal neuralgia affects the trigeminal nerve, one of the largest nerves in the head. The trigeminal nerve sends impulses of touch, pain, pressure, and temperature to the brain from the face, jaw, gums, forehead, and around the eyes.
What Causes Trigeminal Neuralgia?
The most frequent cause of trigeminal neuralgia is a blood vessel pressing on the nerve near the brain stem. Over time, changes in the blood vessels of the brain can result in blood vessels rubbing against the trigeminal nerve root. The constant rubbing with each heartbeat wears away the insulating membrane of the nerve, resulting in nerve irritation.
What Are the Symptoms of Trigeminal Neuralgia?
Trigeminal neuralgia causes a sudden, severe, electric shock-like, or stabbing pain that lasts several seconds. The pain can be felt on the face and around the lips, eyes, nose, scalp, and forehead. Symptoms can be brought on when a person is brushing the teeth, putting on makeup, touching the face, swallowing, or even feeling a slight breeze.
Trigeminal neuralgia is often considered one of the most painful conditions seen in medicine. Usually, the pain is felt on one side of the jaw or cheek, but some people experience pain at different times on both sides. The attacks of pain may be repeated one after the other. They may come and go throughout the day and last for days, weeks, or months at a time. At times, the attacks can disappear for months or years. The disorder is more common in women than in men and rarely affects anyone younger than 50.
How Is Trigeminal Neuralgia Diagnosed?
Magnetic resonance imaging (MRI) can be used to determine whether a tumor or multiple sclerosis is irritating the trigeminal nerve. Otherwise, no test can determine with certainty the presence of trigeminal neuralgia. Tests can, however, help rule out other causes of facial disorders. Trigeminal neuralgia usually is diagnosed based on the patient's description of the symptoms.
How Is Trigeminal Neuralgia Treated?
Trigeminal neuralgia can be treated with antiseizure medications such as Tegretol or Neurontin. The medications Klonopin and Depakote may also be effective and may be used in combination with other drugs to achieve pain relief. Some antidepressant drugs also have significant pain relieving effects.
If medications are ineffective or if they produce undesirable side effects, neurosurgical procedures are available to relieve pressure on the nerve or to reduce nerve sensitivity.
Some patients report having reduced or relieved pain by means of alternative medical therapies such as acupuncture, chiropractic adjustment, self-hypnosis or meditation.
Arachnoiditis is a pain disorder caused by the inflammation of the arachnoid, one of the membranes that surround and protect the nerves of the spinal cord. It is characterized by severe stinging, "burning pain," and neurological problems.
Arachnoiditis has no consistent pattern of symptoms, but in many people it affects the nerves connecting to the lower back and legs. The most common symptom is pain; but, arachnoiditis can also cause:
· Tingling, numbness, or weakness in the legs
· Sensations that may feel like insects crawling on the skin or water trickling down the leg
· Severe shooting pain that can be similar to an electric shock sensation
· Muscle cramps, spasms and uncontrollable twitching
· Bladder, bowel and/or sexual dysfunction
As the disease progresses, symptoms may become more severe or even permanent. Many people with arachnoiditis are unable to work and suffer significant disability because they are in constant pain.
Causes of Arachnoiditis
Inflammation of the arachnoid can lead to the formation of scar tissue and can cause the spinal nerves to stick together and malfunction. The arachnoid can become inflamed because of an irritation from one of the following sources:
· Direct injury to the spine
· Chemicals: Dye used in myelograms (diagnostic tests in which a dye called radiographic contrast media is injected into the area surrounding the spinal cord and nerves) have been blamed for some cases of arachnoiditis. The radiographic contrast media responsible for this is no longer used, however. Also, there is concern that the preservatives found in epidural steroid injections may cause arachnoiditis.
· Infection from bacteria or viruses: Infections such as viral and fungal meningitis or tuberculosis can affect the spine.
· Chronic compression of spinal nerves: Causes for this compression include chronic degenerative disc disease or advanced spinal stenosis (narrowing of spinal column).
· Complications from spinal surgery or other invasive spinal procedures: Similar causes include multiple lumbar (lower back) punctures.
Making the Diagnosis
Diagnosing arachnoiditis can be difficult, but tests such as the CAT scan (computerized axial tomography) or MRI (magnetic resonance imaging) have helped with diagnosis. A test called an electromyogram (EMG) can assess the severity of the ongoing damage to affected nerve roots by using electrical impulses to check nerve function.
Note: Myelograms with the radiographic contrast currently in use, combined with CAT scanning, are not considered to be responsible for causing arachnoiditis or causing it to worsen.
There is no cure for arachnoiditis. Treatment options for arachnoiditis are similar to those for other chronic pain conditions. Most treatments focus on relieving pain and improving symptoms that impair daily activities. Often, health care professionals recommend a program of pain management, physiotherapy, exercise, and psychotherapy. Surgery for arachnoiditis is controversial because outcomes can be poor and provide only short-term relief. Clinical trials of steroid injections and electrical stimulation are needed to determine whether those treatments are effective.
Neuropathy is a disease that damages the nerves and causes them to function abnormally. The pain caused by the damage, dysfunction and/or injury of the nerve tissue is called neuropathic pain. Because nerve fibers exist throughout the body in complex networks, finding the source of the neuropathic pain and getting the proper treatment can de difficult. Neuropathic pain can be the result of any of the following types of neuropathy:
- autonomic neuropathy, which affects the nerves of the body that function automatically without a patient's control (i.e., nerves in the bladder, digestive tract, etc.)
- mononeuritis multiplex,which affects many individual, unconnected nerves at the same time
- mononeuropathy, which affectsnerves in or connected to the brain and/or spinal cord
- polyneuropathy, which affectsmany connected nerves throughout the body.
The most common type of neuropathy is peripheral polyneuropathy that typically affects the limbs. For example, phantom limb pain is a form of peripheral polyneuropathy in which a patient still feels pain in a limb that has been removed from the body. Although researchers continue investigating why phantom limb pain exists, many believe that crossed nerve networks send erroneous messages to the brain that pain is occurring in a limb that is no longer there.
Risk Factors for Neuropathic Pain
About 1.5 percent of Americans and 7.7 percent of
Europeans are believed to be affected by neuropathic pain. However, these estimates are likely on the low side, given that many cases of neuropathic pain go undiagnosed due to the elusive nature of this condition. Some of the factors that put people at risk of developing neuropathic pain include:
- age (People over the age of 40 are more likely to suffer from this condition.)
- chemical imbalances
- ethnicity (Europeans are far more likely to suffer from this condition than those of over ethnicities.) poor circulation
- smoking or chewing tobacco
- suffering or recovering from a serious physical trauma (such as an amputation or a major surgery).
Causes of Neuropathic Pain
Neuropathic pain can be caused by a variety of factors, including:
- facial nerve problems
- HIV or AIDS
- multiple sclerosis
- some types of tumors and cancer.
Keep in mind that there are far more causes of neuropathic pain, some of which still haven't been identified by researchers. With so many possible causes, diagnosing this condition can be especially tricky.
Symptoms of NeuropathyNeuropathy is marked by any combination of the following symptoms:
- allodynias (translated to mean "other pain"), an extreme pain in the response to a non-harmful stimulus
- burning sensations
- dysesthesias, a hallucination of the sensory organs in which the patient feels an odd sensation without the trigger of any stimulus
- pain that continues after the cause of the pain has been removed
- sharp, stinging pain (Many patients describe this pain as feeling like pins and needles.)
- tingling sensations
- warm sensations in the affected area.
If you start experiencing any of these symptoms, consult your doctor immediately for a proper diagnosis. Early diagnosis is essential to making treatments as effective as possible.
Because neuropathies are complex, elusive conditions, they are hard to diagnose. Doctors start the diagnosis process by asking the patient about his and his family's medical history. The doctor will then ask the patient specific questions about his symptoms (i.e., about the type and intensity of the pain, the duration of the symptoms, etc.). Next, the doctor will perform a thorough physical examination on the patient to rule out any other conditions that may be causing the patient to suffer from symptoms similar to those of neuropathy. In addition, doctors will also likely perform a series of tests, including MRIs and CT scans, to complete the physical examination. After performing the exam and analyzing the test results, the doctor will be able to determine whether or not a patient suffers from neuropathy.
While no cure for neuropathy exists, patients do have some treatment options that revolve around minimizing and managing the symptoms. The type of neuropathy treatment that will work best for an individual patient will vary widely depending on the cause of the pain and whether or not the patient suffers from other conditions. In most cases, doctors prescribe one (or a combination) of the following medications:
- antidepressant drugs (specifically tri-cyclic antidepressants)
- non-steroidal anti-inflammatory drugs (NSAIDs)
Doctors may also suggest that the patient undergo transcutaneous electrical nerve stimulation (TENS), a treatment in which electrical waves are fed into the body's pressure points (much in the same way acupuncture uses needles). If diabetes or another underlying condition has caused the neuropathy, talk to your doctor about ways to treat or manage the underlying condition, as it may alleviate the neuropathic pain. However, in some cases, patients do not respond well to any therapies. In these rare instances, the neuropathy tends to worsen over time, eventually leading to serious disability. When nothing else works, doctors may attempt more invasive therapies such as implanting a pain management device to help manage the pain.
What Is Peripheral Neuropathy?
Peripheral neuropathy is damage to the peripheral nervous system which transmits information from the brain and spinal cord to every other part of the body. These are the nerves that sense pain, touch, hot, and cold. They also affect movement and muscle strength.
The nerves in the feet and lower legs are most often affected. This type of nerve damage can lead to serious foot problems. The damage usually gets worse slowly, over months or years. Symptoms may get worse during pregnancy. Peripheral neuropathy can be caused by many different conditions, but one of the most common is diabetes.
Symptoms of Peripheral Neuropathy
- Tingling or burning in your toes, feet, legs, fingers, hands, or arms
- A "pins and needles" feeling
- Pain or cramping
- Numbness or loss of sensation (severe or long term numbness can become permanent)
- Insensitivity to heat and cold
- Extreme sensitivity to even the lightest touch
- Muscle weakness in your hands or feet
- Loss of coordination or balance that makes it harder to walk
- Burning sensation (especially in the evening)
The nerves to your feet are the longest in your body, and they're often the first to be affected. (Nerve pain, numbness, and muscle weakness can also appear in your hips, thighs, and buttocks—called proximal neuropathy—making it hard to walk.)
Types of Nerve Pain
- Diabetic Peripheral Neuropathy
- Postherpetic Neuralgia and Shingles
- Nerve Pain vs. Muscle Pain
Diabetic Peripheral Neuropathy
Diabetes is a lifelong condition in which sugar (glucose) remains in the blood rather than entering the body's cells to be used for energy. This results in high blood sugar, which, over time, can damage many body systems.
Nearly 21 million Americans have diabetes, and at least six out of 10 of them have some kind of nerve damage—called diabetic neuropathy—according to the American Diabetes Association (ADA). Over time, high blood sugar levels can damage nerves throughout your body. The higher your blood sugar levels, the more likely you are to have nerve damage. So controlling your blood sugar throughout your life is very important.
Nerve pain or numbness can happen in anywhere in your body, but the feet and legs are the most common area. Nearly one in three people over age 40 with diabetes has lost some feeling in his or her feet, says the ADA. A little numbness is not a minor problem. Amputation—having a toe, foot, or lower leg surgically removed—is 10 times more likely in people with diabetes.
For people with diabetes, nerve pain can be a serious problem. Nerve damage in the feet can result in a loss of foot sensation, increasing your risk of foot problems and possibly leading to infections. Injuries and sores on the feet may go unrecognized due to lack of sensation. Therefore, you should practice proper skin and foot care.
Postherpetic Neuralgia & Shingles
Sometimes, particularly in older people, symptoms of shingles persist long after the rash has healed. In these cases facial paralysis, headache and persistent pain can be the outcome. Possibly because the nerve cells conveying pain sensations are hardest hit, or are sensitized by the virus attack, pain is the principal persistent complication of shingles.
This pain, called postherpetic neuralgia or PHN, is the kind of pain that leads to insomnia, weight loss, depression and that total preoccupation with unrelenting anguish that characterizes the chronic pain sufferer.
- Although it can be extraordinarily painful, postherpetic neuralgia is not life–threatening
- It is important to realize that individuals with postherpetic neuralgia no longer have shingles because their infection is over. Instead, they are suffering from damage to the nervous system. Scientists believe that the virus attack has led to scarring or other lesions affecting the cells in sensory ganglia and associated nerves. Even in such severe cases, however, the paralysis, headaches, and pain generally subside, although it may take time.
Fibromyalgia syndrome affects the muscles and soft tissue. Fibromyalgia symptoms include chronic pain in the muscles, fatigue, sleep problems and painful tender points or trigger points at certain parts of the body. Fibromyalgia pain and other symptoms can be relieved through medications, lifestyle changes, stress management and other treatments.
Nerve Pain vs. Muscle Pain
The nerve pain that occurs with diabetes is different from other types of pain that you may feel. For example, it is different from the pain you get from a sprained ankle or muscle ache.
There are lots of medicines available for pain, but many products that you are used to taking for headaches, muscle aches, or joint pain have not been clinically proven to calm the stabbing, tingling, burning pain that may be associated with nerve damage.
Peripheral neuropathy can be broadly categorized by the type of nerve that has been damaged. The peripheral nervous system is made up of three types of nerves:
- motor nerves (responsible for voluntary movement)
- sensory nerves (responsible for sensing temperature, pain, touch, and limb positioning); including large and small fibers
- autonomic nerves (responsible for involuntary functions such as breathing, blood pressure, sexual function, digestion)
Peripheral neuropathy also can be classified by where it occurs in the body. Nerve damage that occurs in one area of the body is called mononeuropathy, in many areas, polyneuropathy. When the disorder occurs in the same places on both sides of the body, the condition is called symmetric neuropathy.
It also can be categorized by cause, such as diabetic neuropathy and nutritional neuropathy. When a cause cannot be identified, the condition is called idiopathic neuropathy.
If you have nerve pain, you know that it can take many forms: burning, tingling, electricity, and pins-and-needles are a few of the ways people describe the sensation. But if you have no idea what's causing the pain, you're not alone. Millions of people have unexplained nerve pain. While traditional medicine can offer some relief, there are a number of other ways to lessen the pain.
Known Causes of Nerve Pain
Nerve pain is caused by damage to the nerve. More than 50 medical conditions, drugs, and toxins are known to cause nerve damage, including:
- Diabetes mellitus
- Human immunodeficiency virus (HIV) infection
- Celiac disease
- Fabry's disease
- Medications, including B6 (pyridoxine), isoniazid, HIV medicines, or chemotherapy
- Toxins, such as heavy alcohol drinking
- Autoimmune conditions, such as lupus and vasculitis
Once a nerve is damaged, it is more likely to start behaving abnormally. It may become quiet and send no information, which causes numbness. Or it may send excessive and inappropriate pain messages.
Unexplained Nerve Pain: Searching for Causes
For many people, the cause of nerve pain cannot be identified even after extensive testing. This is called unexplained (idiopathic) nerve pain, or idiopathic neuropathy. Unexplained nerve pain may still be due to nerve damage that occurred at some point, but current medical knowledge and testing can't say how, when, or why.
Between 15 million to 20 million Americans are believed to have unexplained nerve pain -- about one in 10 people over the age of 40. It's most likely to occur in people over 60 years old.
In some studies, almost half of the participants with unexplained nerve pain also had prediabetes. Some experts believe that the elevated blood sugars of prediabetes may be the main cause of this.
Other studies have found that metabolic syndrome -- the combination of high blood pressure, abnormal cholesterol levels, obesity, and prediabetes -- is also common in people with unexplained nerve pain. These factors may contribute to the pain.
Symptoms of Unexplained Nerve Pain
Idiopathic peripheral neuropathy, like diabetic neuropathy, usually causes numbness in the hands and feet. The numbness may go unnoticed if it causes no pain.
Nerve pain in idiopathic peripheral neuropathy is usually in the feet and legs but can also be in the hands and arms. People describe their unexplained nerve pain in different ways:
- Electrical shocks
Simple touching can cause nerve pain, and pain may be constant even when there's no stimulation. Often, unexplained nerve pain is worst at night, interfering with sleep. This can compound the problem because people need adequate sleep in order to cope with pain.
Seeking Medical Care for Unexplained Nerve Pain
Anyone who has nerve pain should get a full physical examination done by a doctor. Get checked for diabetes, high cholesterol, and blood pressure. Get evaluated for recent viral illnesses and toxins to which you may have been exposed. Discuss your full family medical history with the doctor.
Medical therapies are available to treat unexplained nerve pain, and it's worthwhile to discuss them with your doctor. But while medications can help, they usually can't reduce more than half of the pain.
Self-Care and Home Treatment
Several self-care strategies can help you cope and live better with unexplained nerve pain.
- Get moving. Regular exercise may expand blood vessels in the feet over time, nourishing damaged nerves back to health. Start with a daily walk and gradually build up your pace and distance.
- Step up foot care. If you have nerve pain in your feet, examine them daily, wear comfortable shoes, and see a podiatrist regularly.
- Get some sleep. Getting a good night's sleep can be tricky if you have nerve pain. Increase your odds by limiting caffeine intake in the afternoon, keeping a consistent bedtime, and reserving the bedroom for sleep.
- Explore the mind-body connection. Ask your doctor or a trusted friend for a referral to a reputable professional who provides guided imagery, meditation, biofeedback, or hypnosis.
If your nerve pain isn't responding to medicines and your best self-care, it may be time to talk to a neuropathic pain specialist. Your primary care doctor will provide a referral, most likely to a neurologist. A neuropathic pain specialist may be familiar with the multiple "off-label" uses of medicines for nerve pain and be able to provide you with additional help.
Experts describe 10 ways to treat diabetic nerve pain at home.
For millions of people with diabetes, living with nerve pain means learning to improvise. Even the best medicines only cut nerve pain by about half, on average. And some people with diabetes might want to avoid the expense and potential side effects of additional prescription drugs.
Not surprisingly, more than half of people with diabetic neuropathy say they've tried complementary treatments to relieve their nerve pain.
Experts say the urge toward self-care is good. "There are a lot of effective things you can do at home to improve the pain from diabetic neuropathy," says Sue McLaughlin, RD, CDE, president of health care and education for the American Diabetes Association. "You live with it every day, and you can do something positive about it daily, too."
Peripheral Neuropathy: The Not-So-Minor Complication of Diabetes
Diabetic nerve pain is caused by nerve damage, the result of the toxic effects of high blood sugars and poor circulation. Over time, as more nerve fibers are lost, nerves lose their ability to transmit sensation. Numbness in the feet and legs is the common symptom that two-thirds of people with diabetes experience at some point.
The damage also makes nerves more likely to misfire. They may send pain signals in response to ordinary touching or for no apparent reason. "People frequently describe nerve pain as burning, electrical shocks, or pins and needles," says McLaughlin. Nerve pain is usually in the feet and legs, but can also be in the hands.
About 25% of people with diabetes experience nerve pain. Pain can range from annoying to debilitating, even making simple daily activities intolerably painful. Because symptoms are usually worse at night, neuropathic pain often interferes with sleep, and mood problems such as irritability and depression can follow.
"Diabetic peripheral neuropathy is a so-called minor complication of diabetes, but not to the people who live with the pain it creates," says Laurence Kinsella, MD, professor of neurology at Saint Louis University and a fellow with the American Academy of Neurology.
"Medicines, and doctors for that matter, can only do so much. Everyone with this condition should be doing certain things for themselves at home too," Kinsella says.
WebMD asked the diabetes experts for guidance on some of the most widely used home care therapies for diabetic nerve pain. Here are the top 10 strategies -- some old standbys and a few surprises.
The Top Neuropathic Pain Treatment: Controlling Blood Sugar Levels
When it comes to reducing pain from diabetic neuropathy, "controlling your sugar isn't just your No. 1 strategy; it's practically the whole top ten," says McLaughlin.
The toxic effects of high blood sugar are what cause nerve damage and nerve pain in the first place. Continued high sugar "only lets the process continue," says McLaughlin. But keeping sugars close to normal can stop ongoing damage and improve the pain of diabetic neuropathy, studies show. And because some diabetic nerve damage might be reversible, reducing sugar may have even more benefits.
Preventing Neuropathic Pain With Foot Care
Nerve pain is often what brings people with diabetic peripheral neuropathy to see a doctor. But it's numbness in the feet that lands them in the hospital, Kinsella tells WebMD. "It's the little rock you stepped on five days ago without feeling it," Kinsella says, that can lead to "poorly healing ulcers, infections, and even amputations."
Some ways to care for your feet:
- Clean and inspect them every day. "Any sore or ulcer that isn't healing normally is worth showing to a podiatrist or your primary doctor," Kinsella says.
- Wear comfortable shoes. Kinsella suggests asking for help at a store that specializes in shoes for neuropathic feet.
- Wear socks with padding at the ball of the foot and the heel.
- Cut your toenails straight across or allow a podiatrist to cut them for you. When it comes to avoiding complications, says Kinsella, a podiatrist trim "costs about ten bucks, and it's money well spent."
Walking to Heal Damaged Nerves
Because exercise improves blood flow to leg and foot nerves, a regular exercise program may nourish damaged nerves back to health. A landmark study found that a program of regular walking prevented neuropathy in most people with diabetes during the course of the study. Walking also slowed the progression of neuropathy in those who had already developed the condition.
"Exercise helps reduce blood sugars overall," McLaughlin points out, making diabetes easier to control. Also, exercise increases people's tolerance levels for nerve pain, she says.
Warm Water Treatment for Diabetic Neuropathy
Some people find that a regular warm bath provides some relief from mild nerve pain. Warm baths boost blood flow to the skin of the legs and feet. And because they're relaxing and stress- reducing, they can help make pain easier to tolerate.
"Warm baths are a good, safe option," says Kinsella, as long as you're careful about the heat. "Check the water temperature with your arm, not your feet, before stepping in."
Vitamin B Complex May Help Nerve Pain
The B vitamins (B-1, B-12, B-6, and folic acid) are essential for nerve health. Most people get enough B vitamins just from eating a healthy diet, but controlled studies differ on whether taking a B vitamin supplement improves nerve pain.
Kinsella recommends taking daily B vitamins because they are "a generally inexpensive, safe measure that will help some people." He advises 25 milligrams of thiamine (B-1), 500 micrograms of B-12, 25 milligrams of B-6, and at least 1 milligram of folic acid.
He cautions against higher doses of B-6. "Don't go higher than 50 milligrams a day." Kinsella says. Taking the supplement in high doses and long term can lead to toxicity, and cause pain and numbness in the hands and legs, and in severe cases even difficulty walking.
Over-the-Counter Pain Relievers
Acetaminophen, aspirin, ibuprofen (Motrin), and naproxen (Aleve) are better for headaches than nerve pain, most experts say. Still, they can play a part in your home treatment plan for neuropathic pain.
McLaughlin advises talking to your doctor before using them to improve pain. "Some of these medicines can be hard on your kidneys," she says, so never go above your doctor's recommended dosages.
Capsaicin: The Hot Chili Pepper Treatment
Who knew that chili peppers could reduce nerve pain? Made from hot peppers, capsaicin cream rubbed on skin affected by nerve pain can bring relief. In one important study, more than two-thirds of people using capsaicin reported improvement in nerve pain.
Capsaicin does help, but you have to be religious about using it, Kinsella tells WebMD. "You have to apply it three or four times a day and know that for a few weeks, it will feel worse before it gets better."
Less Beer for Less Pain
A drink of alcohol a day can provide health benefits to some people, but it may be too much for those with diabetic neuropathy. "High levels of alcohol are toxic to nerves, especially nerves that are already injured," Kinsella says. Reduce the amount of alcohol you drink. Kinsella advises no more than four drinks per week.
Evening Primrose Oil and Diabetic Neuropathy
Extracted from the evening primrose plant, this oil is rich in omega-6 fatty acids, which are important structural components of cell walls. Theoretically, supplementing the diet with evening primrose oil, which is available in pills, may boost the repair or regrowth of damaged nerves cells.
In two clinical trials, taking evening primrose oil orally improved nerve function somewhat in people with diabetic neuropathy. The risks of evening primrose oil are small, but they include possible increased bleeding in people who take daily aspirin or prescription blood thinners.
It can be necessary to take up to 12 capsules of primrose oil a day to see effects, which some people may find inconvenient. "I know this is out there as a suggested treatment," McLaughlin tells WebMD, "but I don't think there are sufficient studies to support its use."
Botanical Oils for Nerve Pain
Some studies have shown that applying botanical oils such as geranium oil can reduce the pain of postherpetic neuralgia. Other oils, such as lavender oil, have been shown to help relax people, which may also help take the mind off nerve pain.
Alpha-Lipoic Acid May Help Diabetic Peripheral Neuropathy
This potent antioxidant, also called thioctic acid, clears so-called free radicals from the body, potentially reducing nerve damage. In Germany it is used to treat nerve pain and damage from diabetes.
Alpha-lipoic acid given orally or intravenously (600-1,200 milligrams per day) seems to be effective at reducing nerve pain in people with diabetes. For some people, it may help reduce the symptoms of burning, numbness, and prickling in the feet.
"Studies are mixed as to whether alpha-lipoic actually reverses any nerve damage," McLaughlin says.
No major diabetes treatment group has yet endorsed alpha-lipoic acid.
The Most Effective Treatment for Nerve Pain: Keep at It
Unfortunately, there is not enough scientific evidence to provide solid guidance on some of the alternative treatments for diabetic neuropathy pain. But don't let that make you avoid self-care altogether.
"Most people with painful diabetic neuropathy need a combination of both medicines and self-care strategies," says Kinsella. Try low-risk, low-cost options for home care first. And if you're considering supplements, remember that all supplements can have side effects, so tell your doctor about any new treatment you want to try.
Source WebMD Feature
Neuropathy, a common complication of diabetes, is damage to the nerves that allow you to feel sensations such as pain. There are a number of ways that diabetes damages the nerves, and they are all linked to blood glucose (sugar) being too high for a long period of time.
Diabetes-related nerve damage can be painful, but it isn't severe in most cases. There are two major types of diabetic neuropathy: peripheral and autonomic.
The areas of the body most commonly affected by peripheral neuropathy are the feet and legs. Nerve damage in the feet can result in a loss of foot sensation, increasing your risk of foot problems like ulcers. Therefore, proper skin and foot care should be practiced. Rarely, the arms, abdomen, and back may be affected.
Symptoms of peripheral neuropathy may include:
Numbness (severe or long-term numbness can become permanent)
In most cases, symptoms will become less when blood glucose is controlled.
To prevent peripheral neuropathy:
Check your feet and legs daily -- look for blisters, calluses, and cuts.
Apply lotion if your feet are dry but avoid getting lotion in between your toes; this area should be kept dry.
Care for your nails regularly. (Go to a podiatrist if necessary.)
Wear properly fitting footwear. Some people with bony abnormalities may require custom shoes to redistribute pressure.
People with claudication may require a referral to a doctor or surgeon who specializes in poor circulation.
Control blood sugar, cholesterol and high blood pressure
If you smoke, quit
Autonomic neuropathy most often affects the digestive system, especially the stomach, blood vessels, urinary system, and sex organs. To prevent autonomic neuropathy, you need to continuously keep your blood glucose levels well controlled.
Symptoms of neuropathy of the digestive system may include:
Feeling full after small meals
Frequent episode of labile blood sugar control
Treatments may include:
Eat smaller meals
Symptoms of neuropathy of the blood vessels may include:
Blacking out when you stand up quickly
Increased heart rate
Low blood pressure
Treatments may include:
Avoid standing up quickly
Wear special stockings
Symptoms of neuropathy of the male sex organs may include:
Unable to have or maintain an erection (erectile dysfunction)*
"Dry" or reduced ejaculations
External erection maintenance device
Impotence needs to be evaluated by your doctor. It may be caused by your medicines or factors other than diabetes.
Symptoms of neuropathy of the female sex organs may include:
Decrease in vaginal lubrication
Decrease in number of orgasms or lack of orgasm
Symptoms of neuropathy of the urinary system may include:
Unable to completely empty bladder
Increased urinary tract infections
Incontinence (leaking urine)
Increased urination at night
Self-catheterization (inserting a catheter into the bladder to release urine)
Complex regional pain syndrome (CRPS), also called reflex sympathetic dystrophy syndrome, is a chronic pain condition in which high levels of nerve impulses are sent to an affected site. Experts believe that CRPS occurs as a result of dysfunction in the central or peripheral nervous systems.
CRPS is most common in people aged 20-35. The syndrome also can occur in children; it affects women more often than men.
There is no cure for CRPS.
What Causes Complex Regional Pain Syndrome?
CRPS most likely does not have a single cause but rather results from multiple causes that produce similar symptoms. Some theories suggest that pain receptors in the affected part of the body become responsive to catecholamines, a group of nervous system messengers. In cases of injury-related CRPS, the syndrome may be caused by a triggering of the immune response which may lead to the inflammatory symptoms of redness, warmth, and swelling in the affected area. For this reason, it is believed that CRPS may represent a disruption of the healing process.
What Are the Symptoms of Complex Regional Pain Syndrome?
The symptoms of CRPS vary in their severity and length. One symptom of CRPS is continuous, intense pain that gets worse rather than better over time. If CRPS occurs after an injury, it may seem out of proportion to the severity of the injury. Even in cases involving an injury only to a finger or toe, pain can spread to include the entire arm or leg. In some cases, pain can even travel to the opposite extremity. Other symptoms of CRPS include:
- "Burning" pain
- Swelling and stiffness in affected joints
- Motor disability, with decreased ability to move the affected body part
- Changes in nail and hair growth patterns. There may be rapid hair growth or no hair growth.
- Skin changes. CRPS involves changes in skin temperature -- skin on one extremity can feel warmer or cooler compared to the opposite extremity. Skin color changes also are apparent as the skin is often blotchy, pale, purple or red. The texture of skin also can change, becoming shiny and thin. People with syndrome may have skin that sometimes is excessively sweaty.
CRPS may be heightened by emotional stress.
How Is Complex Regional Pain Syndrome Diagnosed?
There is no specific diagnostic test for CRPS, but some testing can rule out other conditions. Triple-phase bone scans can be used to identify changes in the bone and in blood circulation. Some health care providers may apply a stimulus (for example, heat, touch, cold) to determine whether there is pain in a specific area.
Making a firm diagnosis of CRPS may be difficult early in the course of the disorder when symptoms are few or mild. CRPS is diagnosed primarily through observation of the following symptoms:
- The presence of an initial injury
- A higher-than-expected amount of pain from an injury
- A change in appearance of an affected area
- The presence of no other cause of pain or altered appearance
How Is Complex Regional Pain Syndrome Treated?
Since there is no cure for CRPS, the goal of treatment is to relieve painful symptoms associated with the disorder. Therapies used include psychotherapy, physical therapy, and drug treatment, such as topical analgesics, narcotics, corticosteroids, antidepressants and anti-seizure drugs.
Other treatments include:
Sympathetic nerve blocks: These blocks, which are done in a variety of ways, can provide significant pain relief for some people. One kind of block involves placing an anesthetic next to the spine to directly block the sympathetic nerves.
Surgical sympathectomy: This controversial technique destroys the nerves involved in CRPS. Some experts believe it has a favorable outcome, while others feel it makes CRPS worse. The technique should be considered only for people whose pain is dramatically but temporarily relieved by selective sympathetic blocks.
Intrathecal drug pumps: Pumps and implanted catheters are used to send pain-relieving medication into the spinal fluid.
Spinal cord stimulation: This technique, in which electrodes are placed next to the spinal cord, offers relief for many people with the condition.
Central pain syndrome is a neurological condition caused by dysfunction that specifically affects the central nervous system (CNS), which includes the brain, brainstem, and spinal cord.
The disorder occurs in people who have -- or who have experienced -- strokes, multiple sclerosis, limb amputations, brain injuries, or spinal cord injuries and may develop months or years after injury or damage to the CNS.
What Are the Symptoms of Central Pain Syndrome?
Central pain syndrome is characterized by a mixture of pain sensations, the most prominent being a constant burning. The steady burning sensation is sometimes increased by light touch. Pain also increases in the presence of temperature changes, most often cold temperatures. A loss of sensation can occur in affected areas, most prominently on distant parts of the body, such as the hands and feet. There may be brief, intolerable bursts of sharp pain on occasion.
How Is Central Pain Syndrome Treated?
Pain medications often provide little or no relief for those affected by central pain syndrome; however, some antidepressants and anticonvulsants can be useful in treating central pain syndrome. Doctors recommend people with the condition be sedated and the nervous system kept quiet and as free from stress as possible.
(ĐTĐ) - Neuropathic pain can be very difficult to treat with only some 40-60% of patients achieving partial relief.
In addition to the work of Dworkin, O'Connor and Backonja et al., cited above, there have been several recent attempts to derive guidelines for pharmacological therapy. These have combined evidence from randomized controlled trials with expert opinion.
Determining the best treatment for individual patients remains challenging. Attempts to translate scientific studies into best practices are limited by factors such as differences in reference populations and a lack of head-to-head studies. Furthermore, multi-drug combinations and the needs of special populations, such as children, require more study.
It is common practice in medicine to designate classes of medication according to their most common or familiar use e.g. as "antidepressants" and "anti-epileptic drugs" (AED's). These drugs have alternate uses to treat pain because the human nervous system employs common mechanisms for different functions, for example ion channels for impulse generation and neurotransmitters for cell-to-cell signaling.
Favored treatments are certain antidepressants e.g. tricyclics and selective serotonin-norepinephrine re-uptake inhibitors (SNRI's), anticonvulsants, especially pregabalin (Lyrica) and gabapentin (Neurontin), and topical lidocaine. Opioid analgesics and tramadol are recognized as useful agents but are not recommended as first line treatments. Many of the pharmacologic treatments for chronic neuropathic pain decrease the sensitivity of nociceptive receptors, or desensitize C fibers such that they transmit fewer signals.
Some drugs may exert their influence through descending pain modulating pathways. These descending pain modulating pathways originate in the painstem.
The functioning of antidepressants is different in neuropathic pain from that observed in depression. Activation of descending norepinephrinergic and serotonergic pathways to the spinal cord limit pain signals ascending to the pain. Antidepressants will relieve neuropathic pain in non-depressed persons.
In animal models of neuropathic pain it has been found that compounds which only block serotonin reuptake do not improve neuropathic pain.1516171819202122 Similarly, compounds that only block norepinephrine reuptake also do not improve neuropathic pain. Compounds such as duloxetine, venlafaxine, and milnacipran that block both serotonin reuptake and norepinephrine reuptake do improve neuropathic pain.
Bupropion has been found to have surprisingly high efficacy in the treatment of neuropathic pain.
Tricyclic antidepressants may also work on sodium channels in peripheral nerves.
Pregabalin (Lyrica) and gabapentin (Neurontin) work by blocking specific calcium channels on neurons. The actions of the anticonvulsants carbamazepine (Tegretol) and oxcarbazepine (Trileptal), especially effective on trigeminal neuralgia, are principally on sodium channels.
Lamotrigine may have a special role in treating two conditions for which there are few alternatives, namely post stroke pain and HIV/AIDS-related neuropathy in that subgroup on antiretroviral therapy.
Opioids, also known as narcotics, are increasingly recognized as important treatment options for chronic pain. They are not considered first line treatments in neuropathic pain but remain the most consistently effective class of drugs for this condition. Opioids must be used only in appropriate individuals and under close medical supervision.
Several opioids, particularly methadone have NMDA antagonist activity in addition to their µ-opioid agonist properties.
Methadone and ketobemidone possess NMDA antagonism. Methadone does so because it is a racemic mixture; only the l-isomer is a potent µ-opioid agonist.
There is little evidence to indicate that one strong opioid is more effective than another. Expert opinion leans toward the use of methadone for neuropathic pain, in part because of NMDA antagonism. It is reasonable to base the choice of opioid on other factors.
In some forms of neuropathy, especially post-herpetic neuralgia, the topical application of local anesthetics such as lidocaine can provide relief. A transdermal patch containing lidocaine is available commercially in some countries.
Repeated topical applications of capsaicin, are followed by a prolonged period of reduced skin sensibility referred to as desensitization, or nociceptor inactivation. Capsaicin not only depletes substance P but also results in a reversible degeneration of epidermal nerve fibers. Nevertheless, benefits appear to be modest.
Marijuana's active ingredients are called cannabinoids. Unfortunately, strongly held beliefs make discussion of the appropriate use of these substances, in a medical context, difficult. Similar considerations apply to opioids.
A recent study showed smoked marijuana is beneficial in treating symptoms of HIV-associated peripheral neuropathy. Nabilone is an artificial cannabinoid which is significantly more potent than delta-9-tetrahydrocannabinol (THC). Nabilone produces less relief of chronic neuropathic pain and had slightly more side effects than dihydrocodeine.
The predominant adverse effects are CNS depression and cardiovascular effects which are mild and well tolerated but, psychoactive side effects limit their use. A complicating issue may be a narrow therapeutic window; lower doses decrease pain but higher doses have the opposite effect.
Sativex, a fixed dose combination of delta-9-tetrahydrocannabinol (THC) and cannabidiol, is sold as an oromucosal spray. The product is approved in Canada as adjunctive treatment for the symptomatic relief of neuropathic pain in multiple sclerosis, and for cancer related pain.
Long-term studies are needed to assess the probability of weight gain, unwanted psychological influences and other adverse effects.
Botulinum Toxin Type A (Botox, BTX-A)
Botulinum Toxin Type A (BTX-A) is best know by its trade name, Botox. Local intradermal injection of BTX-A is helpful in chronic focal painful neuropathies. The analgesic effects are not dependent on changes in muscle tone. Benefits persist for at least 14 weeks from the time of administration.
The utility of BTX-A in other painful conditions remains to be established.
The N-methyl-D-aspartate (NMDA) receptor seems to play a major role in neuropathic pain and in the development of opioid tolerance. Dextromethorphan is an NMDA antagonist at high doses. Experiments in both animals and humans have established that NMDA antagonists such as ketamine and dextromethorphan can alleviate neuropathic pain and reverse opioid tolerance. Unfortunately, only a few NMDA antagonists are clinically available and their use is limited by unacceptable side effects.
Reducing sympathetic nervous stimulation
In some neuropathic pain syndromes, "crosstalk" occurs between descending sympathetic nerves and ascending sensory nerves. Increases in sympathetic nervous system activity result in an increase of pain; this is known as sympathetically-mediated pain.
Lesioning operations on the sympathetic panch of the autonomic nervous system are sometimes carried out.
There are two dietary supplements that have clinical evidence showing them to be effective treatments of diabetic neuropathy; alpha lipoic acid and benfotiamine.
A 2007 review of studies found that injected (parenteral) administration of alpha lipoic acid (ALA) was found to reduce the various symptoms of peripheral diabetic neuropathy. While some studies on orally administered ALA had suggested a reduction in both the positive symptoms of diabetic neuropathy (including stabbing and burning pain) as well as neuropathic deficits (paresthesia), the metanalysis showed "more conflicting data whether it improves sensory symptoms or just neuropathic deficits alone". There is some limited evidence that ALA is also helpful in some other non-diabetic neuropathies.
Benfotiamine is a lipid-soluble form of thiamine that has several placebo-controlled double-blind trials proving efficacy in treating neuropathy and various other diabetic comorbidities.
In addition to pharmacological treatment several other modalities are commonly recommended. While lacking adequate double blind trials, these have shown to reduce pain and improve patient quality of life for chronic neuropathic pain: chiropractic, yoga, massage, meditation, cognitive therapy, and prescribed exercise. Some pain management specialists will try acupuncture, with variable results.
Transcutaneous electrical nerve stimulation (TENS) may be worth considering in chronic neurogenic pain. TENS, with certain electrical waveforms, appears to have an acupuncture-like function.
Infrared photo therapy has been used to treat neuropathic symptoms. However, recent work has cast doubt on the value of this approach.
Neuromodulation is a field of science, medicine and bioengineering that encompasses both implantable and non-implantable technologies (electrical and chemical) for treatment purposes.
Implanted devices are expensive and carry the risk of complications. Available studies have focused on conditions having a different prevalence than neuropathic pain patients in general. More research is needed to define the range of conditions for which they might be beneficial.
Spinal cord stimulators and implanted spinal pumps
Spinal cord stimulators, use electrodes placed adjacent to, but outside the spinal cord. The overall complication rate is one-third, most commonly due to lead migration or peakage. Lack of pain relief sometimes prompts device removal.
Infusion pumps deliver medication directly to the fluid filled (subarachnoid) space surrounding the spinal cord. Opioids alone or opioids with adjunctive medication (either a local anesthetic or clonidine) or more recently ziconotide are infused. Complications such as, serious infection (meningitis), urinary retention, hormonal disturbance and intrathecal granuloma formation have been noted.
There are no randomized studies of infusion pumps. For selected patients 50% or greater pain relief is achieved in 38% to 56% at six months but declines with the passage of time. These results must be viewed skeptically since placebo effects cannot be evaluated.
Motor cortex stimulation
Stimulation of the primary motor cortex through electrodes placed within the skull but outside the thick meningeal mempane (dura) has been used to treat pain. The level of stimulation is below that for motor stimulation. As compared with spinal stimulation, which requires a noticeable tingling (paresthesia) for benefit, the only palpable effect is pain relief.
Deep pain stimulation
The best long-term results with deep pain stimulation have been reported with targets in the periventricular/periaqueductal grey matter (79%), or the periventricular/periaqueductal grey matter plus thalamus and/or internal capsule (87%). There is a significant complication rate which increase over time.
(ĐTĐ) - Neuropathic pain is a type of pain which is caused by damage to or dysfunction of the nervous system. Neuropathic pain cannot be explained by a single disease process or a single specific location of damage.
Neuropathic pain may be associated with abnormal sensations called dysesthesias, which occur spontaneously and allodynias that occur in response to external stimuli. Neuropathic pain may have continuous and/or episodic (paroxysmal) components. The latter are likened to an electric shock. Common qualities of neuropathic pain includes burning or coldness, "pins and needles" sensations, numbness and itching. Nociceptive pain is more commonly described as aching.
As much as 7% to 8% of the population is affected and in 5% it may be severe. Neuropathic pain may result from disorders of the peripheral nervous system or the central nervous system (pain and spinal cord). Thus, neuropathic pain may be divided into peripheral neuropathic pain, central neuropathic pain, or mixed (peripheral and central) neuropathic pain.
Central neuropathic pain is found in spinal cord injury, multiple sclerosis, and some strokes. Fipomyalgia, a disorder of chronic widespread pain, is potentially a central pain disorder and is responsive to medications that are effective for neuropathic pain.4
Aside from diabetes (see Diabetic neuropathy) and other metabolic conditions, the common causes of painful peripheral neuropathies are herpes zoster infection, HIV-related neuropathies, nutritional deficiencies, toxins, remote manifestations of malignancies, genetic, and immune mediated disorders or physical trauma to a nerve trunk.
Neuropathic pain is common in cancer as a direct result of cancer on peripheral nerves (e.g., compression by a tumor), or as a side effect of chemotherapy, radiation injury or surgery.
The starting point for neuropathic pain is a lesion or dysfunction within the somatosensory system. Current knowledge regarding the mechanisms of neuropathic pain is incomplete and is biased by a focus on animal models of peripheral nerve injury.
Under normal circumstances, pain sensations are carried by unmyelinated and thinly myelinated nerve fibers, designated C-fibers and A-delta fibers respectively. After a peripheral nerve lesion, a neuroma may develop at the stump. The neurons become unusually sensitive and develop spontaneous pathological activity, abnormal excitability, and elevated sensitivity to chemical, thermal and mechanical stimuli. This phenomenon is called "peripheral sensitization".
The dorsal horn neurons give rise to the spinothalamic tract (STT), which constitutes the major ascending nociceptive pathway. As a consequence of ongoing spontaneous activity arising in the periphery, STT neurons develop an increased background activity, enlarged receptive field and increased responses to afferent impulses, including normally innocuous tactile stimuli. This phenomenon is called central sensitization. Central sensitization has been proposed as an important mechanism of persistent neuropathic pain.
Other mechanisms, however, may take place at the central level after peripheral nerve damage. The loss of afferent signals induces functional changes in dorsal horn neurons. A decrease in the large fiber input decreases activity of interneurons inhibiting nociceptive neurons i.e. loss of afferent inhibition. Nociceptive pain can be described as the one that can occur in our everyday life as an aftermath of a simple insult or injury. The mechanism for such type of pain can be generated by transduction, which converts the stimulus into electrical activity in specialized nociceptive primary afferent nerves. Hypoactivity of the descending antinociceptive systems or loss of descending inhibition may be another factor. With loss of neuronal input (deafferentation) the STT neurons begin to fire spontaneously, a phenomenon designated "deafferentation hypersensitivity.”Non-neural glial cells may play a role in central sensitization. Peripheral nerve injury induces glial to releasing glial proinflammatory cytokines and glutamate which, in turn influence neurons.
Mechanisms at light-microscopic and submicroscopic levels
The phenomenon described above are dependent on changes at light-microscopic and submicroscopic levels. Aberrant regeneration, altered expression of ion channels, changes in neurotransmitters and their receptors as well as altered gene expression in response to neural input are at play.