Nerve Pain (Neuropathies)

[Used with permission from the new book, PAIN RELIEF in 4 Simple Steps by Jacob Teitelbaum, MD.]

Is your pain burning, stabbing, shooting or “electric like”? These suggest a nerve pain component.

Neuropathic pain can be triggered by illness (e.g., diabetes, low thyroid), infections (e.g., shingles), pinched nerves (e.g., Carpal Tunnel Syndrome), nutritional deficiencies (e.g., vitamin B6 and B12), nerve injury (e.g., tumors, spinal cord injury, and multiple sclerosis), and medication/treatment side effects (e.g., radiation and chemotherapy, AIDS drugs, macrodantin and Flagyl®).

In addition, chronic pain conditions such as fibromyalgia, chronic Lyme, and Long COVID can trigger a secondary small fiber neuropathy (SFN). Addressing the pain as discussed in this book will usually also help the SFN.

Nerve cells have triggers, like pacemakers, that cause nerve cells to fire. These require energy to stop firing. During low energy states in the nerve cells, they are forced to continue firing until they are exhausted, which contributes to the nerve pain.

Neuropathy often benefits from a different approach than other kinds of pain.

Evaluation

Physicians are usually pretty good at diagnosing nerve pain and its triggers. Still, it’s a good idea to be sure that your doctor has looked for the treatable causes. Lab testing should include:

• A blood count (CBC) and an inflammation/sedimentation rate (ESR or CRP).
• Thyroid testing with a Free T4 and TSH.
• Vitamin B12 level (best kept over 540 pg/ml). Having a high B12 blood level above the normal range is good.
• Screening for diabetes with a glycosylated hemoglobin (HgBA1C).
• Screening for autoimmune illness with an ANA (antinuclear antibody), which is only significant if greater than 1:320. Also screening for thyroid inflammation with an anti-TPO antibody (even if the other thyroid labs are “normal”).

The medical history should be assessed for excess alcohol use, vitamin deficiencies, hereditary factors, or treatment with medications that can cause nerve injury. A neurological examination and a nerve conduction study may also give an indication of the cause.

Common Causes of Nerve Pain

Postherpetic Neuralgia (PHN or Shingles)

Postherpetic Neuralgia follows a rash called herpes zoster. Often called shingles, it is caused by the same virus that causes chickenpox. The first time you get chickenpox, the virus remains in your nerve endings even after the chickenpox is gone. This usually causes no problems. However, if the virus reactivates in one of the nerve endings, it causes a rash all along the distribution of the nerve.

The rash of herpes zoster is characterized by being painful and being in a line totally on one side of your body. If it extends past the midline of your body, the rash is probably coming from something else.

Diabetic Neuropathy

This is the most common cause of neuropathy in the U.S.

Research has shown that some who are labeled as having diabetic neuropathy actually have nerve pain caused by vitamin B6 or B12 deficiency. This can occur even with a normal vitamin B12 blood test. The medication metformin, which is excellent for diabetes, will frequently cause vitamin B12 deficiency. This may then be misdiagnosed as diabetic neuropathy and can be prevented with a good multinutrient powder.

Nutritional Deficiencies

Neuropathic pain can be caused by deficiencies of vitamins B12, B1, B6, E, and zinc. A good multinutrient powder can also take care of these. Excess vitamin B6 (over 45 mg a day for years), however, can worsen neuropathy. A special form of vitamin B6 called P5P (pyridoxal 5 phosphate) is less likely to cause this problem.

Recent research shows that an enzyme defect present in 6% of the population will cause severe B12 deficiency despite totally normal blood levels. The simplest approach to addressing this is by taking a multinutrient powder that has at least 100 micrograms of B12.

I recommend the Energy Revitalization Drink Mix, which optimally addresses all of these.

Hormonal Deficiencies

Hormonal deficiencies, especially an underactive thyroid, can also cause neuropathic as well as muscular pain. A 3–6 month therapeutic trial of thyroid hormone may be reasonable for anybody who also has symptoms of low thyroid, including fatigue, cold intolerance, achiness, having low body temperatures, or unexplained inappropriate weight gain—even if thyroid hormone blood tests are normal, and especially if the anti-TPO antibody test, showing thyroid inflammation, is elevated.

Also, topical bioidentical testosterone cream can help chronic muscle and nerve pain, even if blood levels are normal. In women, I consider a dose of ½–2 mg a day (from a compounding pharmacy). In men, if the testosterone level is under 500 ng/dl, I consider 50–100 mg a day of the topical cream if over 50 years old.  In men under 50, I may substitute the prescription clomiphene 25 mg a night, which stimulates their own testosterone production. Testosterone therapy is best generally avoided in people under 20 years old and in those with certain hormone-sensitive cancers.

Pinched Nerves: Back Pain and Sciatica

A pinched nerve can cause nerve pain in many places in the body. Two of the more common ones are:

1. Low back pain from sciatica, and
2. Pain in the hand, and sometimes wrist and forearm, from Carpal Tunnel Syndrome.

Many, if not most, cases diagnosed as sciatica are actually coming from tight muscles in the back and pelvis.

Complex Regional Pain Syndrome (CRPS/RSD)

CRPS usually manifests as horribly severe pain in one hand or foot after an injury or surgery, but it can then certainly spread elsewhere. The diagnosis is often missed unless somebody sees a pain specialist. Effective treatment is now available.

Effective Treatment of Neuropathy

Fortunately, there are many natural and prescription options that can be very effective.

I Start by Naturally Supporting Nerve Health

Natural treatments can be very effective, so I start with these. Here is the “recipe” that I recommend:

• A well-designed, high-potency multinutrient powder. I recommend the Energy Revitalization Drink Mix.
• Lipoic acid 600 mg a day.
• PEA (Palmitoylethanolamide) for brain pain.
• If the pain is secondary to chemotherapy, then I also add acetyl L-carnitine 1,000 mg twice a day.

These are often introduced one at a time over several days to make sure there are no side effects. Three to six months may be needed to observe the full benefits.

Another option to support nerve health is an excellent product called Healthy Feet and Nerves from Terry Naturally®. This combines lipoic acid, key “nerve-supporting” nutrients, and a special form of vitamin B1 called benfotiamine, which has been studied for nerve health support. These are then combined with PEA as part of a comprehensive approach.

Prescription and Other Therapies

• Cannabinoids can also help nerve pain.
• Add the LDN.
• Consider Frequency Specific Microcurrent.
• Use topical creams for localized areas of nerve pain.

A wonderful addition to the treatment of pain in general, and especially nerve pain, is the use of prescription topical creams. This allows the use of a low dose of many different medications locally, with minimal to no side effects.

These can be very effective. For example, studies have shown that for longstanding shingles pain, using a 5% ketamine cream applied 2–3 times daily over the painful skin areas decreased pain significantly in 65% of cases, usually within days and without side effects. Other studies have also found topical Neurontin and Dilantin® to be effective.

But it is important to have a knowledgeable compounding pharmacist guide you and your physician in prescribing these creams. I recommend working with an experienced compounding pharmacist, such as Allan Jolly, RPh, NMD, at ITC Pharmacy, to help guide you and your physician on prescription-compounded pain creams.

Unfortunately, insurance does not usually cover compounded creams, and they must be made by specialized pharmacies. But they are reasonably priced and often highly effective.

A Prescription-Covered Topical

Lidocaine® patch, 5%. This Novocaine®-like patch is applied directly over the area of maximum pain. It can be cut to fit the area, and up to four patches can be used at a time (although the package insert says only three). It is left on for 12 hours and then removed for 12 hours each day, although reports have suggested that the patch can be left on for up to 18 hours and still be safe and effective. Results will usually be seen within 2 weeks. It should not be used if you have an allergy to Novocaine/lidocaine.

The patches are most likely to be helpful if the pain is localized to a moderately sized area. Even in a large area, however, patches can be used on the most uncomfortable spots. The main downside of the patches is that they are $2–$3 per patch. If one has prescription insurance, however, they will often be covered.

Some clinicians use patches placed over the compounded pain creams as a way to help enhance the cream delivery into the tissues. I leave dry skin by the edge of the lidocaine patch, so it sticks.

Oral Prescriptions

For severe nerve pain, some clinicians may also consider beginning with one of the medications discussed in this section, while incorporating the natural options discussed above.

Basically, it is like trying on different shoes to see what fits best. The good news is that we have a large assortment of “shoes” that you can try on and that are likely to help you. But it can take 6–8 weeks on the optimal dose to see the benefits.

The benefit of these medications is that they are usually covered by insurance. However, they are more likely to have side effects. People with neuropathy often say, “I have tried everything but couldn’t tolerate anything.” If this is you, here’s how to get past that:

1. If you have side effects from a medication, lower the dose to what is comfortable. Though this may not be enough to be effective initially, every 3–8 weeks you’ll usually find that you can increase the dose a bit and your body will be OK as your body adapts. Eventually you can usually find an effective dose that is well tolerated.
2. If you are on an effective dose of one medication, but it is not helping, then it’s time to stop it and go down the list to the next medication. If it helps significantly, but not enough, I often then add the next medication on the list.
3. Sometimes combining lower doses of several medications works better than individual medications at higher doses, and with fewer side effects. This is especially true when combined with the natural options above.

Here are the most helpful medications for nerve pain and, for the first eight, the order in which I use them. For severe nerve pain, I usually begin with one of the medications while adding in all the natural options above.

1. Neurontin (Gabapentin) and Other Related Medications

Neurontin has been shown to be helpful for both shingles and diabetes pain. Dosing is individualized by your physician, commonly up to doses as high as 600 mg, 3–4 times a day. The key side effect is sedation or lightheadedness.

A newer cousin called Lyrica (pregabalin) may be more effective for nerve pain but has more side effects. Common side effects include sedation, dizziness, weight gain (especially at doses over 300 mg a day), and sometimes mild swelling in the ankles when first starting therapy. The usual starting dose is 75 mg twice a day. When going over 300 mg a day, I find an increase in benefits is uncommon, while side effects increase dramatically. Unless the person sees marked benefit at 150–300 mg a day, I will usually add or switch to another medication rather than raise the dose over 300 mg daily.

These medications also have the benefit of improving sleep when taken at nighttime.

2. Tricyclic Antidepressants

Tricyclic antidepressants include medications such as Elavil, Tofranil®, nortriptyline, or doxepin (the latter two are less sedating). Tofranil may be most effective. Sedation, constipation, dry mouth, and weight gain are the most common side effects, although dizziness can also occur. Other side effects include urinary retention, sweating, and abnormal heart rhythms. But these are less common with the lower doses I recommend here.

Many people experience the key pain and sleep benefits at very low doses such as 10–50 mg at bedtime, while higher doses are associated with greater risk of side effects. If adequate relief is not attained at a low dose before uncomfortable side effects occur, I then add the next treatment or switch to another tricyclic instead of pushing the dose to higher levels. If it gave no benefit I would, of course, stop the tricyclics when I began the next treatment. These can be very helpful for nerve pain and have the added benefit of being inexpensive (if you buy the generic form of the drug) while improving sleep (I give it at bedtime).

3. Other Antidepressants

Although antidepressants can be helpful for pain, even if no depression is present, they seem more likely to help nerve pain when they also raise adrenaline (norepinephrine) and not just serotonin. For example, the medication Effexor® can effectively reduce diabetic nerve pain. Interestingly, for this medication, higher doses (225 mg a day) seem more effective for nerve pain than the lower doses used for depression.

Cymbalta (duloxetine) 30–60 mg a day can also be effective for nerve pain.

If used for extended periods, these antidepressants should not be stopped suddenly, as they can cause withdrawal.

4. Ultram (Tramadol®)

Tramadol is an interesting medication that works on many areas of pain and in many different types of pain. Like the antidepressants above, it blocks both norepinephrine and serotonin re-uptake. It also acts on opioid receptors and is generally considered to carry a lower addictive risk than traditional opioids, though dependence can still occur.

Lower doses should be used if combined with antidepressants and other medications that can raise serotonin levels. If not on antidepressants, I begin with a dose of 50 mg twice daily and increase to a maximum of 100 mg 4 times a day. Most people find that a dose of 100 mg 2–3 times daily is helpful and well-tolerated, while doses over 300 mg a day are more commonly associated with nausea.

5. Dilantin (Phenytoin)

Dilantin is another older seizure medication that also can be helpful in many cases of refractory pain. The usual dose is 200 to 400 mg a day, and I recommend checking blood levels with it. It can cause hair growth on the earlobes and overgrowth of gum tissue, which needs to be trimmed away by your dentist. This side effect can be helpful for those with receding gums. It can also be very helpful for neuropathy, without side effects, in a 5–10% topical cream applied over the painful area(s).

6. Topamax (Topiramate®)

Although studies have shown mixed results using Topamax, some people report meaningful improvement. This medication is usually given twice a day at a total daily dose of 50–100 mg for migraines and 200–300 mg a day for nerve pain, although lower doses can be effective.

This is a medication that can help patients who have failed numerous other treatments. It is best to start with a low dose (e.g., 25–50 mg twice a day) and increase by 25 mg per week as able and needed. Side effects include numbness and tingling (paresthesias), cognitive dysfunction, and weight loss (which most people like).

7. Tizanidine (Zanaflex®)

If the other medications do not work adequately, some clinicians consider Zanaflex as an option, as it works through a different mechanism. Zanaflex helps the associated muscle/myofascial pain, which is often present in neuropathy, but missed.

8. Clonidine

Clonidine (Catapres TTS patch 0.1–0.2 mg/day) may help in some cases. NOTE: It lowers blood pressure. If stopped abruptly, it can send blood pressure too high. I use either this or the Zanaflex, but not both together.

9. Capsaicin®

Capsaicin is a natural compound from hot red peppers that can be helpful for nerve pain when applied as a cream. It basically irritates the area so much that it depletes the chemicals that transmit pain. When first using it, some people experience a temporary increase in burning or discomfort. In addition, it needs to be taken on a regular basis to prevent the pain chemicals from building back up. Despite it being a natural compound, I prefer to use other treatments.

10. Benadryl (Diphenhydramine)

Sometimes we get help from unexpected places. Studies have shown that antihistamines can help with nerve pain, despite our not knowing why this works. It has even been found to be helpful in patients who failed treatment with heavy narcotics. I start with 25 mg every 6–8 hours and adjust the dose to the optimum effect (preferably a maximum of 200 mg/day). I do not go over 300–400 mg total per day.

11. Narcotics

Narcotics have been found to be helpful in neuropathic pain. The most common side effects include constipation, sedation, and nausea. Because of side effects and concerns with habituation, as well as the legal issues involved, it is usually best to begin with the other medications I’ve discussed. Narcotics are only modestly helpful but are considered an accepted treatment for severe refractory neuropathic pain.

12. Ketamine

Ketamine is a reasonable option for many kinds of severe persistent pain. The main concern is that it can cause dissociative or hallucinatory effects, which require careful patient counseling and supervised administration, especially at the beginning. The other problem is the price. When given as an IV, or as the newer nasal esketamine, the treatment costs about $800–$1,000 every 3–4 weeks. The work around is that once you get the initial dose or two in a supervised setting (because of its hallucinogenic effects), some compounding pharmacists can make a prescription ketamine nasal spray for just a few dollars a dose.

13. Other Medications

Other medications that can be helpful for rare cases of severe resistant nerve pain, but which I am slow to use because of more severe side effects, include:

• Lamictal (lamotrigine).
• Trileptal ® (oxcarbazepine). This is a cousin to the medication Tegretol®, and both medications are helpful for trigeminal neuralgia.

A more detailed discussion of these and other options, and neuropathy in general, can be found in my earlier book Pain Free 1-2-3.

Summary: I Start with the Nerve Pain Recipe

• Lipoic acid 300 mg twice a day can help the nerves heal directly.
• A well-designed high potency multinutrient powder (I like the Energy Revitalization Drink Mix) to provide broad nutritional support, including nutrients important for general nerve and overall health.
• PEA (Palmitoylethanolamide) 600 mg twice a day for 1 month then 1,200 mg twice a day for 2 months to address the microglial activation that often drives neuropathy. Then people can lower the dose to whatever is needed to maintain the benefit. I use the PEA Healthy Inflammation Response form.
• In those not on narcotics, I also add LDN. Cannabinoids can also be helpful.
• You may speak with your physician about prescribing a customized nerve pain topical cream from a compounding pharmacy such as ITC. Most physicians are not familiar with these, but they can simply authorize the pharmacist to work with you to tailor the cream to your situation.

If there is not enough improvement after several months, many clinicians then consider additional prescription options, such as gabapentin, recognizing that these medications may take up to 12 weeks at a stable dose for full effect.

Addressing both nerve pain and brain pain may provide powerful relief, especially when horrible pain has been present for many years.

You’re Invited! Dr. Teitelbaum is now personally answering questions in his new Facebook support group: Recovering from Fibromyalgia, CFS, and Long COVID. The group is also open to anyone dealing with chronic pain or related health challenges. Join the community, ask your questions, and connect with others!