Pain
Pain
The pain from shingles ranges from mild to severe. Adults with mild pain can try OTC paracetamol alone or in combination with codeine or ibuprofen. If this does not work, or the person presents with, or develops, severe pain, referral is indicated. Prescribers may offer a trial of treatment intended for ‘neuropathic pain’, usually amitriptyline (off-label use), duloxetine (off-label use), gabapentin or pregabalin. Persistent pain is known as post-herpetic neuralgia.
Post-herpetic neuralgia
Following the rash, persistent pain, known as post-herpetic neuralgia (PHN), can develop and is seen more frequently in older people. PHN results from peripheral nerve damage caused by the herpes zoster virus. Pain that persists for 90 days or more after the onset of the rash is a commonly accepted definition for PHN. In PHN:
- Pain is intense and may be described as burning, stabbing, shooting or throbbing
- The affected area may be itchy
- There may be ‘allodynia’: pain is produced by stimuli that are not usually painful, such as a cold draught or heat, or light touch
- Hyperalgesia may be present: there is increased sensitivity (excess pain) to usually mild painful stimuli
- Pain can be debilitating. It can interfere with activities of daily living and can also be so severe that it leads to depression and social isolation
- Insomnia is very common and occurs more frequently in those with more severe pain.
The duration of PHN is highly variable, with up to 50 per cent of people experiencing pain for more than one year, and some having persistent pain for many years. Satisfactory pain relief is challenging and may require the involvement of specialist pain clinics and the use of specialist drugs (often ‘off label’).