Ask Well: When Shingles Pain Lingers

Shingles causes a visible rash, but can also cause lingering pain well after the rash subsides.Credit Getty Images

What are the most effective treatments for postherpetic neuralgia? Are there new treatments that can reduce the need for heavy-duty pain meds?

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Postherpetic neuralgia, a painful nerve disorder that can follow an episode of shingles, can be difficult to treat.

A variety of pain medications are often tried. But no drug has been shown to be more effective against this common neuralgia than the decades-old tricyclic antidepressants, such as nortriptyline, said Dr. Anne Louise Oaklander, an expert in nerve and pain disorders at Massachusetts General Hospital.

But drugs like nortryptyline should not be given an older man with prostate problems, which the drug can aggravate. Alternatives include pregabalin (sold under the brand name Lyrica) or gabapentin, said Dr. Christopher Peter North Watson, a neurologist and pain specialist in Toronto.

In general, these drugs have a modest benefit, Dr. Watson said, but are not effective enough for many patients. They can also have side effects, including rash, diarrhea, stomach upset and confusion.

Postherpetic neuralgia can also improve on its own, he said, though not for everyone, and the process can take years.

The most effective treatment is prevention, Dr. Watson said. The vaccine fpr shingles cuts the chance of contracting it roughly in half and reduces the likelihood of developing postherpetic neuralgia by two-thirds, he said.

Dr. Oaklander said that her research suggested that postherpetic neuralgia was caused by severe loss of neurons in the sensory system as a result of infection with the herpes zoster virus that causes shingles. That leads the nerve cells in the brain or spinal cord to compensate by becoming more sensitive.

She is involved in a study of noninvasive procedures involving brain stimulation – essentially zapping the brain from outside the body with magnetic signals to disrupt the pain signals. She and other researchers are also using low-voltage methods of stimulating the brain. None of these approaches has been approved by the Food and Drug Administration for routine use.

Brain stimulation would probably have fewer side effects than drug treatments, which usually affect the whole body instead of just the brain, Dr. Oaklander said.

“We’re kind of moving on beyond medications, not because they don’t work, but because they have so many side effects,” she said.


