Practice Guideline Briefs

Am Fam Physician. 2005 Feb 15;71(4):808-810.

Treatment of Postherpetic Neuralgia

The Quality Standards Subcommittee of the American Academy of Neurology has released a report on postherpetic neuralgia treatment. “Practice Parameter: Treatment of Postherpetic Neuralgia” appears in the September 2004 issue of Neurology and is available online at http://www.aan.org.

Acute herpetic neuralgia is characterized as burning, aching, electric-shock–like pain, or unbearable itching in association with the outbreak of a herpes zoster rash. The pain is associated with dysesthesias, paresthesias, hyperalgesia, hyperesthesia, and allodynia (production of pain by innocuous stimuli). The pain may precede the onset of the herpetic rash and, rarely, herpetic neuralgia can occur without the development of a rash.

Postherpetic neuralgia, persistence of the pain of herpes zoster more than three months after resolution of the rash, is relatively common, affecting 10 to 15 percent of those with herpes zoster. Zoster-associated pain is used to describe the continuum of pain from acute herpes zoster to the development of postherpetic neuralgia. The time interval used in the clinical case definition of postherpetic neuralgia varies in the literature from one to six months after resolution of the rash. The incidence of postherpetic neuralgia increases with age. The duration of postherpetic neuralgia is highly variable.

Administration of antiviral agents within 72 hours of the onset of herpes zoster can reduce the intensity and duration of acute illness, and can prevent postherpetic neuralgia, as may the use of amitriptyline. Efforts at prevention of herpes zoster and postherpetic neuralgia are important in that 40 to 50 percent of those with postherpetic neuralgia do not respond to any treatment. The practice parameter focused on which treatments provide benefit in terms of decreased pain and improved quality of life. Among the findings and key recommendations are the following:

• Tricyclic antidepressants (amitriptyline, nortriptyline, desipramine, and maprotiline), gabapentin, pregabalin, opioids, and topical lidocaine patches are effective and should be used in the treatment of postherpetic neuralgia. There is limited evidence to support the use of nortriptyline over amitriptyline and the data are insufficient to recommend one opioid over another. Amitriptyline has significant cardiac effects in elderly patients when compared with nortriptyline and desipramine.

• Aspirin in cream may be effective in the relief of pain in patients with postherpetic neuralgia but the magnitude of benefit is low, as with capsaicin.

• In countries where preservative-free intrathecal methylprednisolone is available, it may be considered in the treatment of postherpetic neuralgia.

• Acupuncture, benzydamine cream, dextromethorphan, indomethacin, epidural methylprednisolone, epidural morphine sulfate, iontophoresis of vincristine, lorazepam, vitamin E, and zimelidine are not of benefit.

• The efficacies of carbamazepine, nicardipine, biperiden, chlorprothixene, ketamine, He:Ne laser irradiation, intralesional triamcinolone, cryocautery, topical piroxicam, extract of Ganoderma lucidum, dorsal root entry zone lesions, and stellate ganglion block are unproven in the treatment of postherpetic neuralgia.

• There is insufficient evidence at this time to make any recommendations on the long-term effects of these treatments.

Pain and Anxiety Treatment in Children During Emergencies

The Committee on Pediatric Emergency Medicine and the Section on Anesthesiology and Pain Medicine of the American Academy of Pediatrics (AAP) has released a clinical report on emergency pain and anxiety treatment in children. “Relief of Pain and Anxiety in Pediatric Patients in Emergency Medical Systems” appears in the November 2004 issue of Pediatrics and is available online at http://www.pediatrics.org.

Relief of pain and stress for children receiving emergency medical treatment is a vital, and readily available, component of care. Advances in the recognition and treatment of pain in children over the past 20 years have led to improved pain management for acutely ill and injured children. However, such care still lags behind adult pain management.

Severe pain and stress can have long-lasting implications for children. For example, a newborn infant who undergoes a procedure with inadequate pain relief may have permanent changes in his or her response to, and perceptions of, pain. Post-traumatic stress disorder also can occur after painful procedures and medical experiences. However, there is no evidence that pain management masks symptoms, clouds mental status, or in any way prevents physicians from making adequate assessments and diagnoses, according to the report.

Summary of Recommendations

  • Training and education in pediatric pain assessment and management should be provided to all participants in emergency medical systems for children.

  • Simple methods for creating favorable environmental conditions for infants and children in the emergency medical services (EMS) setting should be advocated by caregivers.

  • Incorporation of child life specialists and others trained in nonpharmacologic stress reduction should be encouraged.

  • Family presence should be offered as an option during painful procedures.

  • Pain assessment for children should begin at admission to EMS and continue until discharge from the emergency department (ED). On discharge, patients should receive detailed instruction regarding analgesic administration.

  • Painless administration of analgesics and anesthetics should be practiced when possible.

  • Neonatal and young infants should receive appropriate pain relief.

  • Administration of pain medication has not been shown to hinder the evaluation of a possible surgical patient in the ED, and pain medication should not be withheld on this account.

  • Sedation should be provided for patients undergoing painful or stressful procedures in the ED. A structured protocol for pediatric sedation, based on recommendations of the American Academy of Pediatrics, American Society of Anesthesiologists, American College of Emergency Physicians, and Emergency Medical Services for Children, should be followed for all children who receive sedative medications in the EMS setting.

Immediate pain assessment for children, including newborns, should occur on emergency department (ED) admission, the report states, and every opportunity should be taken to use available methods of pain control during treatment, even for minor procedures. The recommendations in the report are summarized in the accompanying box.

More research and innovation on child pain and stress reduction techniques are needed, according to the report. As medications and technology evolve, EDs must continue to ensure that safe protocols and practices are in place for child pain management.


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