Nerve Pain (Neuropathic Pain): Causes and Relief

What nerve pain feels like

Nerve pain is different from the dull ache of a sprain or the throbbing of a toothache. Common descriptions:

• burning, as if the skin is scalded or sunburned
• shooting or lightning-like pain along a line
• electric shocks or stabbing jolts
• pins and needles, prickling or crawling
• numbness with pain at the same time

Nerve pain in the skin

When nerves are damaged, the skin can become oversensitive:

• Allodynia: pain from things that should not hurt, such as clothing, bed sheets, a light touch or water.
• Hyperalgesia: exaggerated pain from mildly painful things.
• Pain that builds with sustained touch: some people find skin starts to hurt if it is touched or pressed for a while, or when skin stretches or tightens.

Skin nerve pain over a patch of the upper back, chest or side is often from shingles or nerve root irritation. An itchy or burning patch between the shoulder blades, with skin that looks normal or slightly darker, may be notalgia paresthetica, caused by irritation of small spinal nerve branches. A changed sensation over part of the upper back or neck can also come from a pinched nerve in the neck.

Common causes of nerve pain

Pinched nerve roots (radiculopathy)

A herniated disc, bone spurs or spinal stenosis can press on a nerve as it leaves the spine.

• Neck: cervical radiculopathy causes pain spreading from the neck over the shoulder blade and down the arm, often with tingling in specific fingers and weakness.
• Lower back: sciatica causes pain shooting down the buttock and leg.

Peripheral neuropathy

Peripheral neuropathy is damage to the long nerves, usually starting in both feet with burning, tingling and numbness that creeps upward. Diabetes is the commonest cause in the US. Others include alcohol, vitamin B12 deficiency, chemotherapy, kidney failure, thyroid disease, HIV and some inherited conditions.

Nerve entrapment

• Carpal tunnel syndrome: tingling and pain in the thumb and first fingers, worse at night.
• Cubital tunnel syndrome: little and ring finger symptoms from the ulnar nerve at the elbow.
• Meralgia paresthetica: burning on the outer thigh from a squeezed thigh nerve.
• Morton's neuroma: burning between the toes.

Shingles and postherpetic neuralgia

Shingles causes burning pain in a band on one side of the body, usually followed by a blistering rash. In some people, especially over 60, pain persists for months after the rash heals. This is postherpetic neuralgia. The shingles vaccine reduces the risk.

Facial nerve pain

"Facial nerve pain" usually refers to pain from the trigeminal nerve, which carries sensation from the face. Trigeminal neuralgia causes brief, severe electric-shock pains in the cheek, jaw or teeth, triggered by chewing, talking, brushing teeth or a breeze. (The facial nerve proper controls facial muscles; its disorder, Bell's palsy, causes weakness rather than severe pain.)

Other causes

Multiple sclerosis, stroke (central post-stroke pain), spinal cord injury, complex regional pain syndrome after an injury, nerve injury from surgery or trauma, and tumors pressing on nerves.

Nerve pain from the shoulder to the arm: rotator cuff or nerve?

Shoulder problems and neck nerve problems are commonly confused, and they can coexist.

A weak rotator cuff or shoulder impingement causes pain referred down the upper arm, but it is not true nerve pain and does not usually cause tingling in the hand. Pain with tingling below the elbow points more to the neck. Rarely, shoulder problems involve a nerve directly, for example suprascapular nerve entrapment or brachial neuritis.

How doctors diagnose nerve pain

A doctor will ask where the pain is, what it feels like, what triggers it and whether there is numbness or weakness. They test sensation (light touch, pinprick, vibration), strength and reflexes, and map the pain to a nerve or nerve root.

Tests may include:

• blood tests: glucose and HbA1c, B12, thyroid, kidney and liver function, and others depending on the history
• nerve conduction studies and electromyography (EMG)
• MRI of the spine for suspected nerve root compression
• skin biopsy for small-fiber neuropathy, which causes burning pain with normal nerve conduction studies

Treatment

Treat the cause

Improve blood sugar control, correct B12 deficiency, stop alcohol, release a trapped nerve, treat shingles early with antivirals, or decompress a pinched nerve root.

Medicines for nerve pain

Standard painkillers such as acetaminophen and ibuprofen usually help little. Guidelines recommend:

• Gabapentinoids: gabapentin or pregabalin
• Certain antidepressants: amitriptyline, nortriptyline or duloxetine, which act on pain pathways at low doses
• Carbamazepine for trigeminal neuralgia
• Topical treatments: lidocaine patches or high-strength capsaicin patches for localized pain
• Opioids are generally avoided for long-term nerve pain because of limited benefit and significant risks

These are prescription medicines started at a low dose and increased gradually. It can take several weeks to judge whether one helps.

Other treatments

• physical therapy and exercise
• TENS (a small device that sends mild electrical pulses through the skin)
• nerve blocks or steroid injections for some nerve root and entrapment problems
• spinal cord stimulation for severe, persistent pain
• psychological approaches such as cognitive behavioral therapy, which help people cope and improve sleep

Self-care

• Protect numb feet: check them daily, wear well-fitting shoes, and test bath water with your elbow.
• Wear soft, loose clothing over sensitive skin.
• Cool (not ice-cold) compresses can ease burning.
• Keep active, sleep well and limit alcohol.

Frequently asked questions

What does nerve pain feel like?

Nerve pain is usually burning, shooting, stabbing or like an electric shock, often with tingling, pins and needles or numbness. Skin can become painful to light touch. It often follows the path of a nerve, such as down an arm or leg, or affects both feet.

Why is my skin so sensitive to touch, like nerve pain?

Damaged or irritated nerves can make the skin oversensitive, so clothing, touch or water hurts. This is called allodynia. Causes include shingles, a pinched spinal nerve, neuropathy and complex regional pain syndrome. If there is a one-sided burning band, see a doctor quickly to check for shingles.

Can shoulder impingement cause nerve pain?

Shoulder impingement causes aching pain in the outer shoulder and upper arm when lifting the arm, but it does not usually irritate nerves directly. Burning or shooting pain with tingling in the forearm or hand suggests a pinched nerve in the neck instead.

What is the definition of facial nerve pain?

Facial nerve pain usually means pain from the trigeminal nerve, which carries feeling from the face. Trigeminal neuralgia is the classic example, with brief, severe electric-shock pains in the cheek, jaw or teeth. Shingles on the face and nerve injury after dental work are other causes.

What is the best treatment for nerve pain?

It depends on the cause. Treating the cause comes first. For the pain itself, gabapentin, pregabalin, duloxetine and amitriptyline are first-line medicines, and lidocaine or capsaicin patches help localized pain. Physical therapy and good sleep also matter.