Neuropathic Pain

What is Neuropathic Pain?

Neuropathic pain is caused by damage to or a disease of the system that transmits and processes sensations from the body, known as the somatosensory system.^{1, 2} It can originate in the peripheral nerves, which are located outside the brain and spinal cord, or in either of these two organs. The spinal cord is a cord of nervous tissue within the spine; it transmits messages between the brain and the body.

Nociceptive pain is associated with actual or potential injury to tissues other than nerves, involving the activation of their nerve receptors. Neuropathic pain, on the other hand, involves a lesion or disease of the sensory system.^{2, 1} In both cases, pain is a personal experience. It cannot be deduced simply from nerve activity.³ Several mechanisms may also coexist in the same person.

How to recognize neuropathic pain?

Neuropathic pain can cause a burning sensation, electric shocks, tingling, or pain from light touch. These sensations provide clues; they are not sufficient on their own to confirm this type of pain.⁴ Their distribution does not always follow the precise path of a nerve.⁵

Characteristic Sensations

Neuropathic pain is often distinguished by specific sensations that people describe as:

• Burning: an intense heat sensation, like a burn

• Electric Shocks: sudden, brief pains, like lightning flashes

• Tingling: pins and needles, a prickling sensation

• Numbness: a loss of sensation that may occur alongside pain

• Painful Cold: an intense and unpleasant cold sensation

• Hypersensitivity to Touch: even a light touch becomes painful

The Distribution of Pain

In compression neuropathies, pain may extend beyond the territory of the affected nerve or nerve root. A nerve root is the portion of a nerve near the spinal cord. The corresponding area of skin is called a dermatome; symptoms do not always follow its boundaries.⁵ The clinician therefore looks for a distribution consistent with the suspected condition, without requiring a perfect pattern.⁴

Associated Phenomena

Two phenomena are particularly characteristic:

Allodynia: pain caused by touch or another stimulus that is normally painless. For example, the sensation of sheets touching your feet becomes painful.
Hyperalgesia: pain that is more intense than expected in response to a stimulus that is normally painful.²

What causes neuropathic pain?

Neuropathic pain can be caused by nerve compression, diabetes, shingles, or a disease of the brain or spinal cord.¹ Not all of these conditions cause pain in every person.

Peripheral neuropathy

Peripheral neuropathy affects one or more nerves outside the brain and spinal cord. It can occur in the following situations:

At the level of the nerve roots:

• A cervical herniated disc—a portion of the cushion between two neck bones that protrudes—can compress a nerve root.

• Sciatica—pain that radiates down the leg—may be related to a nerve root in the lower back, such as the L5 or S1 roots.

• Cervicobrachialgia is neck pain that radiates down the arm. It may be associated with nerve root involvement, but this is not always the case.

• Cervical stenosis—a narrowing of the passageway for nerves in the neck—can compress a nerve root.

At the peripheral nerves:

• Carpal tunnel syndrome compresses the median nerve at the wrist and can cause symptoms in the hand.

• Diabetic neuropathy is nerve damage caused by diabetes. It often affects the feet.

• Pain may persist after shingles along the path of the affected nerve. This pain is called postherpetic neuralgia.

• A mass or injury can compress or damage a nerve.

Central Neuropathy

When the spinal cord or brain are affected:

• Pain may occur after a stroke, which disrupts blood flow to the brain.

• Multiple sclerosis attacks the protective sheath surrounding certain nerve fibers in the brain and spinal cord.

• A spinal cord injury can alter sensations and cause pain.

• Damage to the thalamus—a region of the brain that transmits sensations, among other things—can cause central pain.

What is the difference between neuropathic pain and nerve sensitivity to movement?

Neuropathic pain involves damage to or a disease of the sensory system, whereas a nerve’s sensitivity to movement describes a reaction that can occur with or without damage.^{1, 6} These two elements can coexist; they are not interchangeable.

An Important Distinction

The term “neurogenic” refers to nervous system structures. The term “neuromeningeal” refers to nerves and their sheaths. These terms alone are not sufficient to establish a diagnosis or rule out a lesion. The examination must distinguish between a reaction to movement, loss of sensation or strength, and signs of a nervous system disorder.⁶

The sheaths surrounding a nerve may contribute to its sensitivity. Experimental studies show, in particular, that inflammation of these sheaths can increase the reaction to movement without causing significant damage to the nerve fibers. This represents a possible mechanism, not an explanation that has been confirmed in every individual.⁶

A test that replicates pain by stimulating nerve structures provides a clue. It does not, on its own, confirm a nerve injury. Conversely, some people with a confirmed nerve injury test negative.⁶ The result must be interpreted in the context of the entire examination.⁷

For example, the Lasègue test involves gradually raising your straightened leg while you are lying down. This movement affects the nervous system and other tissues. The healthcare professional observes whether your symptoms recur and how they change in response to other movements in order to interpret the results.⁶ Pain during this test therefore does not prove the presence or absence of a lesion.

This distinction has implications for treatment:

• For carpal tunnel syndrome, treatments that combine advice, exercises, and manual techniques can improve symptoms in the short term. The 2020 review describes trials supporting these programs, but the evidence regarding nerve-sliding exercises alone is limited and inconsistent.⁶ The choice of treatment takes into account the examination findings and your preferences.

How is neuropathic pain diagnosed?

The diagnosis of neuropathic pain is based on the patient’s symptom history and an examination of sensation, strength, and reflexes—the body’s automatic responses. Questionnaires and additional tests can help clarify the problem.^{4, 8}

Clinical evaluation

The diagnosis primarily relies on:

History of Symptoms:

• Description of sensations (burning, electric shocks, etc.)

• An area of pain consistent with nerves or sensory pathways that may be affected.

• An injury, surgery, or illness that could explain the symptoms, even if the exact time of onset isn't always clear.

The Physical Examination:

• Areas of allodynia (pain from light touch)

• Areas of hypoesthesia (decreased sensation)

• Tests of nerve function, known as neurodynamic tests.

• Reflexes and muscle strength

Screening questionnaires

Questionnaires can identify signs consistent with neuropathic pain. They do not confirm the diagnosis on their own.⁸ They focus in particular on pain sensations and, in some cases, on sensitivity tests.

• DN4 (Neuropathic Pain in 4 Questions)

• LANSS, a scale that combines symptoms and signs observed during a physical examination

• painDETECT, a questionnaire on pain sensations and distribution.

Additional tests

Additional tests are selected based on the suspected problem; not all of them are necessary for every person.⁶

• Electromyography (EMG): records the electrical activity of muscles to help diagnose certain nerve or muscle disorders

• Magnetic resonance imaging (MRI): produces detailed images that can reveal a lesion or compression. The results should be consistent with the symptoms and the physical examination

• Nerve conduction studies: assess the transmission of electrical signals in certain nerves

How is neuropathic pain treated?

Treatment for neuropathic pain may include addressing the underlying cause, appropriate medications, physical therapy, and strategies for resuming activities.⁶ A major review from 2025 supports several medications, while noting that their average benefits remain modest and that some uncertainties persist.⁹

Complementary Treatments

Treatment aims to relieve symptoms, address their underlying causes when possible, and improve your ability to perform activities that are important to you. The same treatment approach does not automatically work for all neurological conditions.⁶

For compression neuropathies, the recommendations outlined in the 2020 review typically suggest non-surgical treatment as the first line of care.⁶ However, significant or progressive weakness, or symptoms that persist despite treatment, may warrant a surgical consultation.

Medical treatment

Certain medications can relieve neuropathic pain. The choice of medication depends on the diagnosis, other medications, and side effects.⁹ Not all of the following options are suitable for everyone:

• Anticonvulsants, medications also used to treat epileptic seizures, such as gabapentin and pregabalin

• Some antidepressants, such as duloxetine or amitriptyline, can also reduce pain even in the absence of depression

• Products applied to the skin, such as lidocaine, which reduces sensitivity locally, or capsaicin, derived from chili peppers, for certain localized nerve pains

Not all medications for neuropathic pain work the same way. They are reevaluated based on pain relief, daily activities, and side effects.¹⁰ In a trial involving 73 people with mild or moderate carpal tunnel syndrome, the analysis showed no reduction in symptoms with tenoxicam after two or four weeks. Prednisolone, a medication in the cortisone family, improved symptom scores at four weeks.¹¹ The 2020 review found no advantage over a placebo for nonsteroidal anti-inflammatory drugs (NSAIDs), such as tenoxicam, taken orally for this condition.⁶ This finding does not automatically apply to all causes of pain.

Physiotherapy

Physiotherapy plays an important role in managing neuropathic pain:

Pain Education

Explanations about pain help you understand your symptoms, discuss your concerns, and prepare to resume your activities. A review of 13 trials reported favorable results for several outcomes, including pain and functional ability.¹² Another review of 12 trials found small to moderate effects on pain and functional limitations, but a more pronounced benefit regarding fear of movement in the short term.¹³ These studies focused on persistent muscle and joint pain; they did not focus solely on neuropathic pain.

Nerve mobilization

Nerve mobilization uses specific movements to shift nerve structures relative to surrounding tissues. It can help some people regain movement with fewer symptoms. Several mechanisms have been proposed, but relief from symptoms does not necessarily mean that a nerve has been physically unblocked.⁵

For pain that radiates from the lower back down the leg, a review of 21 studies involving 914 people found that nerve mobilization was effective in reducing pain compared to control treatments.¹⁴ The results regarding activity limitations varied across groups. Differences between studies and their high risk of bias limit the certainty of the conclusions.

In a trial involving 20 people with mild or moderate carpal tunnel syndrome, one week of wearing a night splint or performing nerve- and tendon-gliding exercises reduced an MRI signal used as an indicator of swelling within the median nerve. Symptoms and function also improved slightly.¹⁵ The authors suggest that a reduction in this swelling is a possible mechanism. This does not prove that all exercise reduces inflammation or that it can never worsen symptoms. The type of movement and its progression should be tailored to your response.⁵

Gradual exposure

Gradual exposure reintroduces movements and activities that have been avoided, in stages tailored to your symptoms and with the help of a professional.

Desensitization

Desensitization involves gradually exposing a sensitive area to tolerable stimuli, such as different textures. The professional adjusts the stimuli based on your reaction.

Endurance activity

Walking, biking, or other activities that allow you to maintain a steady pace can be part of the plan. Their duration and intensity are tailored to your tolerance, strength, and health.

For some cases of sciatica, surgery provides faster relief initially than non-surgical treatment. However, the cited reviews do not find any long-term superiority over prolonged non-surgical management.^{16, 6} The choice depends, in particular, on the cause, loss of strength, progression of the condition, and your preferences. A significant or progressive loss of strength or sensation requires prompt medical attention.

What you can do

• Maintain an appropriate activity level despite the pain

• Gradually resume activities that have become difficult, without pushing yourself too hard despite a significant worsening of your condition

• Take care of your sleep and report any frequent awakenings or difficulty sleeping. A review of large follow-up studies found an association between sleep problems and persistent muscle and joint pain. The reverse relationship is less clear in the long term. These findings do not apply exclusively to neuropathic pain.¹⁷

• Find ways to manage stress and anxiety related to pain, with support as needed

How does neuropathic pain progress?

Neuropathic pain may subside, persist, or worsen depending on its cause and course. Appropriate care can relieve symptoms and improve daily functioning, though it does not guarantee that all pain will disappear.^{6, 9}

What Influences Its Progression

In compression neuropathies, symptoms may improve, remain stable, or worsen. The 2020 review highlights that initial pain, imaging findings, and emotional or social factors are imperfect predictors of pain persistence, particularly in sciatica.⁶ Monitoring strength, sensation, sleep, and activities helps tailor care.

• Emotional and social factors can influence the experience of chronic pain. Compression neuropathy can also affect mood, work, and relationships. Their exact role in the persistence of these neuropathies remains less well established.⁶

A Message of Hope

Even if neuropathic pain persists, there are several ways to improve your quality of life and resume your activities. Treatment may include a combination of:

• A medical treatment selected and reevaluated based on its effects.

• Tailored physiotherapy

• Strategies for managing daily activities, sleep, and symptoms.

• Explanations tailored to your specific problem and questions.

The nervous system can change its function and structure; this ability is called plasticity. Some of the changes observed in persistent pain diminish as the pain resolves.¹⁸ These observations do not allow us to predict your recovery or to attribute this adaptation to a specific treatment.

When should you see a doctor?

Pain accompanied by a burning sensation, electric shocks, numbness, or unusual sensitivity to touch warrants a medical consultation if it persists or limits your activities. New-onset weakness or the urgent symptoms described below require a more immediate evaluation.

Consult a healthcare professional if you experience:

• Persistent burning sensations, electric shock-like feelings, or tingling

• Pain that follows a nerve's path

• Hypersensitivity to touch

• Numbness accompanied by pain

• Symptoms that persist despite treatment with commonly used pain medications

The evaluation seeks to identify the cause of the symptoms and guides the choice of treatment.

Go to the emergency room immediately if you experience new difficulty urinating, an inability to urinate, unusual loss of bladder or bowel control, a loss of the sensation of needing to have a bowel movement, or a loss of sensation around the genitals or anus. Sciatica on both sides, or severe or worsening weakness or numbness in both legs, also requires evaluation in the emergency room.¹⁹

Rapidly progressing weakness requires urgent evaluation.²⁰ Back pain, fever, chills, or general malaise also require urgent medical attention.²¹

What should we take away from this?

Neuropathic pain is caused by damage to or a disease of the sensory system. The patient’s medical history, a physical examination, and sometimes diagnostic tests help guide appropriate care to relieve pain and facilitate daily activities.

• Neuropathic pain results from an injury or disease affecting the system that transmits and processes sensory information

• Characteristic Sensations include burning, electric shock-like feelings, tingling, and hypersensitivity.

• The diagnosis is based on the patient's history of symptoms, a physical examination, and sometimes additional tests

• Treatment may include appropriate medications, physical therapy, and strategies for daily activities

• The nervous system can adapt; however, this ability does not guarantee a specific treatment timeline or outcome.

If you are experiencing arm pain associated with neck and arm pain or leg pain related to sciatica, a professional evaluation can determine the nerve-related aspect of your condition.

What other resources should I consult?

The pages on chronic pain, how pain works, acute pain, and noceplastic pain round out this guide. Noceplastic pain refers to pain associated with a change in signal processing, without tissue or nerve damage sufficient to explain it.² The management strategies also offer practical tips for daily life.

• Understanding Chronic Pain

• How Pain Works

• Recent pain and persistent pain

• Nociplastic pain

• Pain Management Strategies

References

Links open in a new tab.

1. Treede RD, Jensen TS, Campbell JN, Cruccu G, Dostrovsky JO, Griffin JW, et al. Neuropathic pain: redefinition and a grading system for clinical and research purposes. Neurology. 2008;70(18):1630-5. (Back to sections: 1, 2, 3, 4)
2. International Association for the Study of Pain. Terminology. (Back to sections: 1, 2, 3, 4)
3. Raja SN, Carr DB, Cohen M, Finnerup NB, Flor H, Gibson S, et al. The revised International Association for the Study of Pain definition of pain: concepts, challenges, and compromises. Pain. 2020;161(9):1976-1982. (Back to section: 1)
4. Finnerup NB, Haroutounian S, Kamerman P, Baron R, Bennett DLH, Bouhassira D, et al. Neuropathic pain: an updated grading system for research and clinical practice. Pain. 2016;157(8):1599-1606. (Back to sections: 1, 2, 3)
5. Schmid AB, Nee RJ, Coppieters MW. Reappraising entrapment neuropathies—mechanisms, diagnosis, and management. Man Ther. 2013;18(6):449-57. (Back to sections: 1, 2, 3, 4)
6. Schmid AB, Fundaun J, Tampin B. Entrapment neuropathies: a contemporary approach to pathophysiology, clinical assessment, and management. Pain Rep. 2020;5(4):e829. (Back to sections: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15)
7. Schmid AB, Hailey L, Tampin B. Entrapment Neuropathies: Challenging Common Beliefs With Novel Evidence. J Orthop Sports Phys Ther. 2018;48(2):58-62. (Back to section: 1)
8. Truini A, Aleksovska K, Anderson CC, Attal N, Baron R, Bennett DL, et al. Joint European Academy of Neurology-European Pain Federation-Neuropathic Pain Special Interest Group of the International Association for the Study of Pain guidelines on the assessment of neuropathic pain. Eur J Neurol. 2023;30(8):2177-2196. (Back to sections: 1, 2)
9. Soliman N, Moisset X, Ferraro MC, de Andrade DC, Baron R, Belton J, et al. Pharmacotherapy and non-invasive neuromodulation for neuropathic pain: a systematic review and meta-analysis. Lancet Neurol. 2025;24(5):413-428. (Back to sections: 1, 2, 3)
10. NICE. Recommendations | Neuropathic Pain in Adults: Pharmacological Management in Non-Specialist Settings | Guidance | NICE. (Back to section: 1)
11. Chang MH, Chiang HT, Lee SS, Ger LP, Lo YK. Oral medication of choice for carpal tunnel syndrome. Neurology. 1998;51(2):390-3. (Back to section: 1)
12. Louw A, Zimney K, Puentedura EJ, Diener I. The efficacy of pain neuroscience education on musculoskeletal pain: A systematic review of the literature. Physiother Theory Pract. 2016;32(5):332-55. (Back to section: 1)
13. Watson JA, Ryan CG, Cooper L, Ellington D, Whittle R, Lavender M, et al. Pain Neuroscience Education for Adults With Chronic Musculoskeletal Pain: A Mixed-Methods Systematic Review and Meta-Analysis. J Pain. 2019;20(10):1140.e1-1140.e22. (Back to section: 1)
14. Murape T, Ainslie TR, Basson CA, Schmid AB. Does the efficacy of neurodynamic treatments depend on the presence and type of criteria used to define neural mechanosensitivity in spinally referred leg pain? A systematic review and meta-analysis. S Afr J Physiother. 2022;78(1):1627. (Back to section: 1)
15. Schmid AB, Elliott JM, Strudwick MW, Little M, Coppieters MW. Effect of splinting and exercise on intraneural edema of the median nerve in carpal tunnel syndrome—an MRI study to reveal therapeutic mechanisms. J Orthop Res. 2012;30(8):1343-50. (Back to section: 1)
16. Valat JP, Genevay S, Marty M, Rozenberg S, Koes B. Sciatica. Best Pract Res Clin Rheumatol. 2010;24(2):241-52. (Back to section: 1)
17. Runge N, Ahmed I, Saueressig T, Perea J, Labie C, Mairesse O, et al. The bidirectional relationship between sleep problems and chronic musculoskeletal pain: a systematic review with meta-analysis. Pain. 2024;165(11):2455-2467. (Back to section: 1)
18. Henry DE, Chiodo AE, Yang W. Central nervous system reorganization in a variety of chronic pain conditions: a review. PM R. 2011;3(12):1116-25. (Back to section: 1)
19. nhs.uk. Sciatica. 2017. (Back to section: 1)
20. nhs.uk. Guillain-Barré syndrome. 2017. (Back to section: 1)
21. nhs.uk. Back pain. 2017. (Back to section: 1)