What is neuropathic pain and how does it differ from ordinary pain?
Pain is broadly divided into two distinct biological categories:
| Pain Feature | Nociceptive (Ordinary) Pain | Neuropathic (Nerve) Pain |
|---|---|---|
| Underlying Cause | Tissue inflammation, trauma, or injury (e.g. sprained ankle, osteoarthritis, surgical cut) | Damage, disease, or dysfunction directly affecting sensory nerves, spinal cord, or brain |
| Typical Sensation | Dull ache, throbbing, soreness, sharp tenderness | Burning, electric shocks, stabbing, shooting, freezing, pins and needles, crawling skin |
| Allodynia / Hyperalgesia | Rare | Very common: light touch from clothes, bedsheets, or a breeze can feel excruciating |
| Response to Paracetamol / NSAIDs | Often effective (reduces prostaglandins) | Ineffective: standard painkillers cannot calm damaged electrical signalling |
| Standard Treatments | Paracetamol, ibuprofen, naproxen, physiotherapy | Pregabalin, gabapentin, duloxetine, amitriptyline, capsaicin patches |
Specific nerve pain conditions treated in the UK
1. Diabetic Peripheral Neuropathy (DPN)
Prolonged high blood glucose in diabetes damages the microvascular blood supply feeding peripheral nerves. This causes a classic "stocking-and-glove" distribution of severe burning, tingling, and numbness in the feet and lower legs. Pregabalin is widely prescribed across the NHS as an effective treatment to reduce nighttime burning pain and restore sleep.
2. Post-Herpetic Neuralgia (PHN)
Following an episode of herpes zoster (shingles), the varicella-zoster virus can cause lasting inflammatory damage to sensory dermatomes. Patients experience relentless, burning, and lancinating pain that persists long after the rash has healed. Pregabalin is licensed and strongly evidenced to reduce PHN pain intensity.
3. Central Neuropathic Pain (Spinal Injury & Stroke)
Damage directly within the central nervous system—such as following a traumatic spinal cord injury, post-stroke central pain syndrome (Dejerine-Roussy syndrome), or multiple sclerosis—causes constant, intractable central burning pain. Pregabalin is one of the few medications specifically licensed and clinically proven to help central neuropathic pain.
4. Trigeminal Neuralgia
Severe, sudden, electric-shock facial pain along the trigeminal nerve. While carbamazepine remains the primary first-line treatment, Pregabalin is frequently used as a secondary option or add-on therapy if carbamazepine is ineffective or causes liver or blood toxicity.
How Pregabalin calms nerve pain
When peripheral nerves are injured, they begin generating continuous, spontaneous electrical impulses into the dorsal horn of the spinal cord. This continuous barrage leads to central sensitization, where spinal interneurons become hyper-reactive and amplify every signal reaching the brain.
Pregabalin binds tightly to the α2δ subunit of voltage-gated calcium channels in presynaptic terminals within the dorsal horn. By blocking calcium influx, it cuts off the release of excitatory neurotransmitters (such as glutamate and substance P). This effectively turns down the volume of the incoming pain signals before they can ascend the spinal cord to the brain. Learn more in our mechanism of action guide.
NICE CG173: The UK treatment pathway
Under NICE Clinical Guideline CG173, NHS clinicians are advised to choose from four first-line medications for neuropathic pain:
- Pregabalin (gabapentinoid)
- Gabapentin (gabapentinoid; read our Pregabalin vs Gabapentin comparison)
- Amitriptyline (tricyclic antidepressant, often preferred if sleep is severely broken)
- Duloxetine (serotonin-noradrenaline reuptake inhibitor, often preferred if the patient also experiences low mood or has diabetic neuropathy)
If the first medicine trialled does not provide at least 30% pain relief or causes intolerable side effects, the clinician will switch to one of the remaining three options or trial a combination under specialist guidance.
What does realistic improvement look like?
It is essential to have realistic expectations before starting Pregabalin:
- Nerve pain is rarely reduced to zero: Completely curing neuropathic pain is uncommon. The realistic goal of therapy is a 30% to 50% reduction in pain severity.
- Restoring function: A successful outcome means being able to sleep through the night, wear socks and shoes without distress, walk to the shops, and participate in family activities with less exhaustion.
- Review point: NICE recommends an explicit clinical review 4 to 8 weeks after reaching your maintenance dose. If benefit is not noticeable, your doctor will supervise a gradual taper off the medicine rather than leaving you on an ineffective prescription indefinitely.
Non-drug management alongside Pregabalin
Pregabalin works best as one component of a broader, multidisciplinary pain management plan:
- Diabetic foot care & glucose control: Optimizing HbA1c levels prevents progressive capillary damage to nerve endings.
- Transcutaneous Electrical Nerve Stimulation (TENS): Mild electrical pulses that can help block local nerve pain pathways.
- Pacing and gentle exercise: Tailored physiotherapy to maintain joint mobility and muscle strength without provoking flare-ups.
- Pain psychology and CBT: Cognitive behavioural therapy techniques to manage the emotional toll and sleep disruption of chronic pain.