What role do adjuvant medications play in the management of neuropathic pain, and which should I consider?

Role of adjuvant medications in neuropathic pain management: Adjuvant medications are used to specifically target neuropathic pain mechanisms and improve pain control when standard analgesics are insufficient. They help reduce pain severity, improve quality of life, and address associated symptoms such as sleep disturbance and psychological distress. These medications require careful dose titration to balance efficacy and tolerability, and patients should be informed about potential side effects and the slow onset of benefits.

Specific medications to consider: For neuropathic pain (excluding trigeminal neuralgia), offer a choice of amitriptyline (a tricyclic antidepressant), duloxetine (a serotonin-norepinephrine reuptake inhibitor), gabapentin, or pregabalin (both gabapentinoids). Dosages should be titrated according to response and tolerability. Gabapentin and pregabalin require careful evaluation for history of drug abuse and monitoring for dependence due to their controlled drug status. Combination therapy with these drugs is not recommended due to lack of evidence. Tramadol may be considered only as short-term rescue therapy while awaiting specialist referral. Capsaicin cream can be considered for localized neuropathic pain if oral treatments are unsuitable or not tolerated.

For trigeminal neuralgia, carbamazepine is the first-line treatment, with specialist referral if ineffective or not tolerated.

Other medications such as cannabis sativa extract, capsaicin patches, lacosamide, lamotrigine, levetiracetam, morphine, oxcarbazepine, topiramate, venlafaxine, and long-term tramadol are not recommended in non-specialist settings due to insufficient evidence or safety concerns.