From the Guidelines
Gabapentin, starting at 300 mg daily and gradually increasing, is the most effective analgesic for herpes zoster (shingles) pain management, especially when combined with antiviral medications like acyclovir, valacyclovir, or famciclovir, which should be started within 72 hours of rash onset. For pain management, acetaminophen or NSAIDs like ibuprofen can help with mild pain [ 1 ]. More severe pain may require prescription medications such as pregabalin, tricyclic antidepressants like amitriptyline (10-25 mg at bedtime), or in severe cases, opioids [ 1 ]. Topical options include lidocaine patches (5%) applied to the affected area for 12 hours daily or capsaicin cream [ 1 ]. These medications work by either fighting the virus directly (antivirals), reducing inflammation (NSAIDs), or disrupting pain signals to the brain (gabapentin, tricyclics) [ 1 ]. Early treatment is crucial as it can reduce the duration and severity of pain, as well as lower the risk of developing postherpetic neuralgia, a persistent pain condition that can last months or years after the rash heals. Some key points to consider when managing shingles pain include:
- Starting antiviral medications within 72 hours of rash onset to maximize their effectiveness
- Using a combination of pain management strategies, such as acetaminophen, NSAIDs, and prescription medications, to achieve optimal pain relief
- Considering topical options, such as lidocaine patches or capsaicin cream, for localized pain relief
- Monitoring patients for potential side effects of medications and adjusting treatment plans as needed.
From the FDA Drug Label
The efficacy of pregabalin for the management of postherpetic neuralgia was established in three double-blind, placebo-controlled, multicenter studies These studies enrolled patients with neuralgia persisting for at least 3 months following healing of herpes zoster rash and a minimum baseline score of greater than or equal to 4 on an 11-point numerical pain rating scale ranging from 0 (no pain) to 10 (worst possible pain) Treatment with pregabalin statistically significantly improved the endpoint mean pain score and increased the proportion of patients with at least a 50% reduction in pain score from baseline Gabapentin was evaluated for the management of postherpetic neuralgia (PHN) in two randomized, double-blind, placebo-controlled, multicenter studies Both studies demonstrated efficacy compared to placebo at all doses tested The reduction in weekly mean pain scores was seen by Week 1 in both studies, and was maintained to the end of treatment
Effective analgesics for herpes zoster (shingles) include:
- Pregabalin: shown to be effective in managing postherpetic neuralgia, a complication of shingles, by improving mean pain scores and increasing the proportion of patients with at least a 50% reduction in pain score from baseline 2
- Gabapentin: demonstrated efficacy in two randomized, double-blind, placebo-controlled, multicenter studies for the management of postherpetic neuralgia, with reduction in weekly mean pain scores seen by Week 1 and maintained to the end of treatment 3
From the Research
Effective Analgesics for Herpes Zoster (Shingles)
- Antivirals should be started within 72 hours of onset to reduce the severity and duration of the eruptive phase and to reduce the intensity of acute pain 4.
- For post-herpetic neuralgia (PHN), the following systemic agents can be considered:
- Topical agents that can be effective for PHN include:
- A combination of both topical and systemic agents may be required for optimal outcomes 6.
- Pregabalin may be an effective first-line therapy for PHN and other forms of neuropathic and chronic pain 7.
- Therapy with pregabalin is better compared to amitriptyline in postherpetic neuralgia patients, with satisfactory improvements of pain perception at the end of 8 weeks (>75%) 8.