What is Neuropathic Pain?
Neuropathic pain comes from overactive or sensitised nerves rather than active infection or damage.
Neuropathic pain medications:
- Calm nerve signals
- Reduce pain sensitivity
- Improve sleep (which helps pain control)
Alternatives to Medication
- Nerve blocks – can help in diagnosis
- Lidocaine – topical lidocaine gel or lidocaine 5% plasters contain local anaesthetic that numbs the area to reduce symptoms
- Capsaicin – capsaicin cream or capsaicin 8% patches contain chilli pepper derivatives which reduce the activity of pain-transmitting nerve fibres in the skin
Commonly Used Neuropathic Pain Medications
| Amitriptyline / Nortriptyline | Gabapentin | Pregabalin | Duloxetine | |
| Frequency | Once at night | 2-3 times per day | Twice daily | Once daily |
| Titration | Start at 10 mg at night Increase by 10 mg every 1–2 weeks | Day 1–3: 100–300 mg at night Day 4–6: 300 mg twice daily Then increase every few days toward 900 mg+ | Start: 25–75 mg at night Increase after 3–7 days to twice daily | Week 1: 30 mg Wee 2-8: 60 mg Consider increasing to 90 mg if still symptoms after week 8 |
| Typical Dose | 30–75 mg/day | 900–2400 mg/day | 150–300 mg/day | 60-90 mg/day |
| Onset | Some improvement: 2–4 weeks Full benefit: 6–8 weeks | May help within 1–3 weeks, but often needs higher doses | Slightly faster than gabapentin with a more predictable effect | May help within 1-2 weeks Full benefit: 4-8 weeks |
| Common side effects (these often improve after the first few weeks) | Sleepiness Dry mouth Constipation | Sleepiness Dizziness Weight gain | Sleepiness Dizziness Weight gain | Mild insomnia Nausea Dry mouth Dizziness Reduced appetite |
Important things to remember about neuropathic pain medication
- Nerve pain is treatable
- These are not standard painkillers and do not work immediately
- Stopping early is the most common reason that treatment fails
- The dose needs to be high enough – very low doses rarely help pain
- Your doctor will increase the dose slowly to find the correct level
- You may feel side effects before pain relief; this is normal and usually improves with time
- Once working, treatment is usually continued for 3–6 months, then reduced gradually
- If one medicine helps partially, a second may be added
- Most treatment failures happen because patients stop at low doses or give up too early – persistence gives the best results
Amitriptyline Example Weekly Dose Increase Chart
(Take once nightly unless told otherwise)
| Week | Dose | What to expect |
| 1 | 10 mg | May feel sleepy or slightly “groggy” in the morning |
| 2 | 20 mg | Side effects may still be present; pain usually unchanged |
| 3 | 30 mg | Some early pain improvement may begin |
| 4 | 40 mg | Sleep often better; pain may start reducing |
| 5 | 50 mg | More consistent pain relief in some patients |
| 6 | 60 mg | Assess benefit with your clinician |
| 7+ | 60-75 mg | Typical effective range |
- If you miss a dose: skip it and continue the next night, do not double up
- Stay at your current dose if: you are getting good pain relief, or side effects are limiting increases