Identify and treat specific local pain generators, if present

Cutaneous stimulators (e.g., transcutaneous electrical nerve stimulation)

Local treatment (e.g., physical therapy, manipulation, massage, heat)

Minor interventions (e.g., anesthetic or steroid joint injection)

Surgery

Topical anesthetics (e.g., lidocaine ointment or patches)

Promote healthy behaviors

Physical activity

Weight control

Restore sleep

Depending on coexisting problems, useful agents may include trazodone, tricyclic antidepressants, gabapentin (Neurontin), pregabalin (Lyrica), mirtazapine (Remeron), melatonin, or quetiapine (Seroquel); use of benzodiazepines or their analogs should be avoided because of tolerance and abuse potential

Start adjuvant pain medications (listed in order of recommended treatments)

Tricyclic antidepressants are indicated for neuropathic pain; nortriptyline (Pamelor), desipramine (Norpramin), amitriptyline, and doxepin are also useful for localized or generalized pain with coexisting headache, depression, panic disorder, or tobacco addiction

Serotonin-norepinephrine reuptake inhibitors are indicated for neuropathic pain; duloxetine (Cymbalta) and milnacipran (Savella) are most effective for localized or generalized pain with depression or anxiety, venlafaxine (Effexor) less so; doses for treatment of pain tend to be higher than those for depression

Pregabalin is approved by the U.S. Food and Drug Administration for neuropathic pain and fibromyalgia; gabapentin has similar effectiveness, is available generically, and is more widely used, but it is sedating, and dosing is complex; may be synergistic when combined with tricyclic antidepressants

Anticonvulsants; carbamazepine (Tegretol) is a first-line agent for trigeminal neuralgia, but third-line (with oxcarbazepine [Trileptal] and lamotrigine [Lamictal]) for other neuropathic pain

Migraine chemoprophylaxis (e.g., beta blockers, calcium channel blockers, tricyclic antidepressants, topiramate [Topamax])

Treat comorbid psychiatric illness

Use of pharmacologic and psychotherapeutic measures is essential for improvement of symptoms and function

Commonly associated disorders include anxiety, depression, posttraumatic stress disorder in persons who have experienced physical, sexual, or emotional trauma; treatment should include psychotherapy, biofeedback, mindfulness training, posttraumatic stress disorder therapy, relationship counseling, social and financial counseling, and substance abuse counseling

Trial of opioid therapy (initiation or continuation)

Patients should have no contraindications for opioid therapy

Patients with diffuse, centralized pain or headache are less likely to benefit from opioid therapy and may be harmed by opioid toxicities

Select patients with specific somatic, peripheral, or neuropathic pain may benefit from low-dose opioid therapy in combination with other treatments

Treatment should produce demonstrable functional improvement, not merely a reduction in pain scores, or opioids should be tapered or discontinued