What are the treatment options for nerve pain in the hand?

Treatment of Nerve Pain in the Hand

For nerve pain in the hand, initiate treatment with duloxetine (60 mg daily) or a gabapentinoid (gabapentin 300-3600 mg/day or pregabalin 150-600 mg/day) as first-line therapy, combined with topical lidocaine for localized peripheral neuropathic pain. 1

Diagnostic Considerations Before Treatment

Before initiating therapy, determine the specific nerve involved and pain characteristics:

• Median nerve involvement (carpal tunnel syndrome): Numbness/tingling in thumb, index, and middle fingers; symptoms reproduced by wrist hyperflexion (Phalen's test) or median nerve percussion (Tinel's sign) 2, 3
• Ulnar nerve involvement: Decreased sensation in little finger and ulnar aspect of ring finger, with intrinsic muscle weakness 2
• Radial nerve involvement: Often accompanies lateral epicondylitis; radial nerve block can help differentiate 2
• Neuropathic quality assessment: Burning, stinging, aching pain with photophobia or allodynia suggests central neuropathic component 1, 4

Ultrasound is highly sensitive and specific for diagnosing carpal tunnel syndrome and can identify space-occupying lesions or anatomic variants 1

First-Line Pharmacological Treatment

Oral Medications

Duloxetine (SSNRI):

• Start 30 mg daily, increase to target dose of 60 mg daily 1
• Most robust evidence in neuropathic pain with 59% response rate vs 38% placebo 1
• Allow 3-4 months at therapeutic dose to assess efficacy 1
• Particularly effective for neuropathic pain with comorbid depression 1

Gabapentinoids (if duloxetine fails or is contraindicated):

• Pregabalin: Start 75 mg twice daily, titrate to 150-300 mg twice daily (maximum 600 mg/day) 1, 5
• Gabapentin: Start 300 mg daily, titrate to 300-1200 mg three times daily (maximum 3600 mg/day) 1, 6
• Gabapentinoids have established efficacy in postherpetic neuralgia and diabetic neuropathy 5, 6
• Apply for at least 2 weeks at appropriate dose before switching agents 1

Tricyclic Antidepressants (alternative first-line):

• Use secondary amines (nortriptyline or desipramine) to reduce anticholinergic effects 1
• Start with low doses at bedtime, titrate slowly 1
• Obtain screening ECG for patients >40 years; limit dose to <100 mg/day in cardiac disease 1
• Allow 6-8 weeks for adequate trial, including 2 weeks at highest tolerated dose 1

Topical Treatments

Topical Lidocaine:

• Preferred for localized peripheral neuropathic pain 1
• Can be used alone or combined with oral first-line agents 1
• Minimal systemic effects 1

Capsaicin 8% Patches:

• Apply to affected area for 30-60 minutes; effect lasts up to 90 days 1, 7
• Most established efficacy in other neuropathic pain conditions 1
• Consider for refractory cases 1

Low-concentration Menthol Cream (1%):

• Apply twice daily to affected area and corresponding dermatomal spine region 1
• Minimal toxicity, low cost 1
• Evidence shows substantial pain relief in 31 of 38 patients 1

Second-Line Treatment

If first-line medications fail after adequate trial:

Tramadol:

• Dose: 200-400 mg daily in divided doses (extended-release formulation) 1
• Dual mechanism: opioid receptor agonist and serotonin-norepinephrine reuptake inhibitor 1
• Number needed to treat: 4.7 1

Strong Opioids (salvage option only):

• Use smallest effective dose 1
• Number needed to treat: 4.3 1
• No compelling data support one opioid over another for neuropathic hand pain 1
• Reserve for severe refractory cases 1

Treatment Algorithm

Step 1: Initiate duloxetine 60 mg daily OR gabapentin/pregabalin at target doses, plus topical lidocaine for localized pain 1

Step 2: If partial relief after 3-4 months, add a second first-line medication from different class 1

Step 3: If inadequate relief (<30% reduction) after adequate trial, switch to alternative first-line medication 1

Step 4: Consider tramadol or refer to pain specialist if first-line combinations fail 1

Specific Considerations for Carpal Tunnel Syndrome

If nerve pain is due to carpal tunnel syndrome:

• Volar splinting (especially nocturnal) provides symptom relief 2, 3
• Steroid injection into carpal tunnel often ameliorates symptoms 2, 3
• Refer to hand specialist for severe symptoms or uncertain diagnosis 3
• Surgical decompression for refractory cases 2

Common Pitfalls

• Inadequate dosing duration: All neuromodulators require 3-4 months at therapeutic dose before declaring treatment failure 1
• Premature medication switching: Allow at least 2 weeks at appropriate dose before changing agents 1
• Ignoring cardiac risk with TCAs: Always obtain ECG in patients >40 years before prescribing tricyclics 1
• Overlooking topical options: Topical treatments provide efficacy with minimal systemic effects and should be used early 1
• Failing to address comorbidities: Depression and anxiety commonly accompany neuropathic pain and require concurrent treatment 1, 4
• Using NSAIDs or corticosteroids systemically: No data support benefit of NSAIDs or systemic glucocorticoids for neuropathic hand pain 1