What is the treatment for paresthesias and sharp pains all over the body?

Treatment of Paresthesias and Sharp Pains All Over Body

Start with pregabalin or gabapentin as first-line pharmacologic therapy for widespread neuropathic pain, combined with topical lidocaine patches for any localized areas of pain. 1, 2

Initial Diagnostic Considerations

Before initiating treatment, identify the underlying mechanism:

• Neuropathic pain is characterized by burning, tingling, shooting sensations and is caused by nerve injury or dysfunction 3, 2
• Central causes include stroke, multiple sclerosis, or spinal cord lesions—look for associated neurologic deficits, asymmetric distribution, or sudden onset 4, 5
• Peripheral causes include diabetic neuropathy, nutritional deficiencies (B12, thiamine), metabolic disorders, or toxic exposures 4
• Fibromyalgia presents with widespread pain and paresthesias, often with fatigue and sleep disturbance 6

Critical red flags requiring urgent evaluation: sudden onset with weakness, altered mental status, or focal neurologic deficits suggesting stroke or spinal cord compression 6, 4

First-Line Pharmacologic Treatment

Anticonvulsants with calcium-modulating actions are the primary treatment:

• Pregabalin is FDA-approved for neuropathic pain from diabetes, post-herpetic neuralgia, fibromyalgia, and spinal cord injury 1, 2
• Start pregabalin at low doses and titrate up to minimize dizziness and somnolence 1
• Gabapentin is equally effective as an alternative calcium-modulating anticonvulsant 6, 2

Warning: Pregabalin can cause serious breathing problems when combined with opioids or other sedating medications, and may cause suicidal thoughts in approximately 1 in 500 patients 1

Topical Therapy for Localized Components

Even with widespread pain, add topical treatments to any focal areas:

• Lidocaine patches (4-5%) provide effective relief with minimal systemic absorption and can be cut to fit affected areas 7
• Apply up to 3 patches simultaneously for broader coverage 7
• Capsaicin cream (0.025-0.075%) applied 3-4 times daily, though initial burning sensation is common 6, 7

Second-Line Pharmacologic Options

If inadequate response to anticonvulsants after 2-4 weeks:

• Tricyclic antidepressants (amitriptyline, nortriptyline) are effective for neuropathic pain but carry higher risk of sedation and falls 6, 2
• Serotonin-norepinephrine reuptake inhibitors (duloxetine) are recommended as second-line therapy for chronic pain 6, 2
• Tramadol can be considered before opioids, as it has dual mechanism (opioid and monoamine reuptake inhibition) 6

Avoid opioids as routine therapy for chronic widespread pain given small benefits, uncertain long-term efficacy, and significant risks including respiratory depression and addiction 6

Non-Pharmacologic Approaches

For fibromyalgia or chronic widespread pain:

• Exercise programs are strongly recommended as initial therapy 6
• Cognitive behavioral therapy addresses pain-related anxiety and catastrophizing 6
• Acupuncture has moderate-quality evidence for chronic pain 6
• Mindfulness-based stress reduction and tai chi show benefit 6

Treatment Algorithm

1. Immediate: Rule out stroke, spinal cord compression, or other emergent causes if sudden onset or with neurologic deficits 6, 4, 5

2. Week 1-2: Start pregabalin or gabapentin at low dose, titrate based on response and tolerability 1, 2

3. Week 1-2: Apply lidocaine patches to any focal areas of pain 7

4. Week 2-4: If partial response, add tricyclic antidepressant or duloxetine 2

5. Week 4-8: If inadequate response, consider switching anticonvulsant or adding capsaicin to focal areas 7, 3

6. Ongoing: Incorporate exercise, physical therapy, and psychological support throughout treatment 6

Common Pitfalls

• Do not combine pregabalin with opioids or benzodiazepines without careful monitoring due to respiratory depression risk 1
• Monitor for suicidal ideation when starting anticonvulsants, especially in first few weeks 1
• Avoid NSAIDs as monotherapy for neuropathic pain—they are ineffective for nerve-related pain mechanisms 6, 3
• Screen for reversible causes: diabetes, B12 deficiency, thyroid disease, alcohol use before assuming idiopathic etiology 4
• Warn patients about sedation with pregabalin/gabapentin and advise against driving until effects are known 1