What is the treatment for tingling and numbness?

Treatment for Tingling and Numbness

Duloxetine is the first-line pharmacological treatment for tingling and numbness, particularly for chemotherapy-induced peripheral neuropathy (CIPN) with symptoms of pain, numbness, and tingling. 1

First-Line Treatments

Pharmacological Approaches

• Duloxetine: Strong evidence supports duloxetine as the most effective pharmacological treatment for neuropathic symptoms including tingling and numbness, particularly in CIPN 1

  • Dosing typically starts at 20-30 mg/day and increases to 40-60 mg/day 1
  • When discontinuing, taper slowly to avoid withdrawal symptoms 1

• Pregabalin: May be considered for neuropathic pain, numbness, and tingling, particularly in diabetic peripheral neuropathy 1, 2

  • Works by binding to alpha2-delta subunit of voltage-gated calcium channels in the central nervous system 2
  • Can reduce calcium-dependent release of pro-nociceptive neurotransmitters 2

Non-Pharmacological Approaches

• Physical activity/exercise: Recommended for management of peripheral neuropathy symptoms including tingling and numbness 1

  • Exercise has shown improvement in CIPN symptoms of hot/coldness in hands/feet and reduction in numbness and tingling 1
  • A structured exercise program can result in approximately half a point reduction on a 0-10 scale compared to controls 1

• Acupuncture: May provide relief for tingling and numbness symptoms 1

  • Has shown promise in reducing aromatase inhibitor-associated symptoms including numbness and tingling 1

Second-Line Treatments

• Scrambler therapy: May be beneficial for established CIPN symptoms including tingling and numbness 1

  • In one phase II trial, twice as many scrambler therapy-treated patients had at least 50% improvement in pain, tingling, and numbness compared to TENS-treated patients 1
  • Patients receiving scrambler therapy were more likely to recommend their treatment to others 1

• Transcutaneous Electrical Nerve Stimulation (TENS): May provide some relief but appears less effective than scrambler therapy 1

Treatments Not Recommended

• Topical amitriptyline/ketamine: Not recommended as it showed no effect on CIPN scores in a large randomized placebo-controlled trial 1

• Oral mucosal cannabinoid extract: Not recommended due to lack of benefit and increased toxicity (fatigue, dry mouth, dizziness, and nausea) 1

• Acetyl-L-carnitine: Not recommended as newer larger trials showed no benefit for treating chemotherapy-induced neuropathy 1

Diagnostic Approach

• Assess for underlying causes of tingling and numbness before initiating treatment 1

  • Evaluate for symmetrical length-dependent patterns (glove and stocking distribution) 1
  • Check for sensory loss, including light touch, vibration sense, pin prick, and proprioception 1
  • Consider small fiber neuropathy if burning sensations are present 1

• For diabetic patients, perform annual assessment for peripheral neuropathy 1

  • Use 10-g monofilament testing to identify feet at risk 1
  • Assess temperature or pinprick sensation (small fiber function) and vibration sensation using 128-Hz tuning fork (large fiber function) 1

Special Considerations

• In cancer survivors, especially those who received chemotherapy, assess for CIPN which may manifest as numbness and tingling in hands and/or feet 1

• For patients with trigger points, consider dry needling which may relieve upper extremity numbness and tingling in some cases 3

• In athletes with transient quadriplegia symptoms including numbness and tingling, evaluate for cervical spinal stenosis 4

Treatment Algorithm

1. Identify underlying cause of tingling and numbness
2. First-line treatment:
   • Start duloxetine (if no contraindications)
   • Implement regular physical activity/exercise program
3. If inadequate response:
   • Consider adding pregabalin
   • Refer for acupuncture
4. For refractory symptoms:
   • Consider scrambler therapy
   • Evaluate for specialist referral based on underlying etiology

Common Pitfalls and Caveats

• Failure to identify the underlying cause of tingling and numbness may lead to ineffective treatment 1
• Abrupt discontinuation of duloxetine can lead to withdrawal symptoms; always taper slowly 1
• Not all tingling sensations are pathological; they can be induced by both peripheral stimulation and higher cognitive processes 5
• Numb chin syndrome may be an overlooked symptom of underlying malignancy 6