What pain medication is recommended for shingles?

Pain Management for Shingles

For acute shingles pain, start with acetaminophen or NSAIDs (like ibuprofen or diclofenac) for mild pain, escalate to opioids (such as controlled-release oxycodone) for moderate-to-severe pain, and add gabapentin or pregabalin as adjunctive therapy for neuropathic pain components. 1, 2

Acute Pain Management Algorithm

Mild Pain (Pain Score 1-4)

• Start with acetaminophen/paracetamol 500-1000 mg every 6 hours (maximum 4000-6000 mg daily) 1
• Alternative: NSAIDs such as ibuprofen 400-600 mg four times daily (maximum 2400 mg/day) or diclofenac 50 mg four times daily 1
• When using NSAIDs for more than a few days, add gastric protection (proton pump inhibitor) 1
• Exercise caution with NSAIDs in patients with renal impairment or bleeding risk 1

Moderate-to-Severe Pain (Pain Score 5-10)

• Controlled-release oxycodone is the most evidence-based opioid for acute shingles pain, starting at 10-20 mg every 12 hours 2
• The randomized trial demonstrated that CR-oxycodone significantly reduced worst pain over the first 1-2 weeks compared to placebo (p=0.01 for days 1-8) 2
• Provide "breakthrough" doses of immediate-release opioid equivalent to 10-15% of total daily dose for pain exacerbations 1
• If more than four breakthrough doses per day are needed, increase the baseline opioid dose 1
• Continue opioid therapy until pain resolves, typically within 2-4 weeks as the rash heals 2

Neuropathic Pain Component

• Add gabapentin or pregabalin as adjunctive therapy when pain has burning, shooting, or electric quality 3, 4, 5
• Gabapentin: Start 300 mg once daily at bedtime, titrate to 300 mg three times daily over 3-7 days, then increase as needed up to 1800-3600 mg/day in divided doses 3, 5
• Pregabalin: Start 75 mg twice daily, can increase to 150-300 mg twice daily based on response 4, 5
• Note that gabapentin 300 mg three times daily (low dose) was NOT effective for preventing postherpetic neuralgia in one trial, suggesting higher doses may be needed for adequate pain control 6
• The evidence for gabapentin in acute shingles pain is mixed—one randomized trial found it did not provide significantly greater pain relief than placebo, though data suggested modest benefit in the first week 2

Topical Therapies

• Lidocaine 5% patches can be applied daily to painful areas as adjunctive therapy 7, 8
• Topical lidocaine has minimal systemic absorption and is particularly useful when oral NSAIDs are contraindicated (e.g., anticoagulation, renal impairment) 7
• Capsaicin cream can be considered but may cause initial burning sensation 8, 5

Important Caveats and Pitfalls

Opioid Management

• Constipation is the most common reason for discontinuation of oxycodone (occurred in 27.6% of subjects in the trial) 2
• Start a bowel regimen prophylactically with stool softeners and stimulant laxatives when initiating opioids 2
• Monitor for sedation, dizziness, and respiratory depression, especially in elderly patients 1

Gabapentin/Pregabalin Warnings

• Both medications carry FDA warnings for suicidal thoughts, serious allergic reactions, and respiratory depression when combined with opioids 3, 4
• Start at low doses and titrate slowly to minimize dizziness and somnolence 3, 4
• Dose adjustment required for renal impairment 3, 4
• Do not stop abruptly—taper gradually to avoid withdrawal seizures 3

NSAID Precautions

• Always take NSAIDs with food to minimize gastrointestinal toxicity 9
• Monitor for gastrointestinal bleeding, renal dysfunction, and cardiovascular events with prolonged use 1, 9
• Avoid in patients with active peptic ulcer disease, severe renal impairment, or recent cardiovascular events 1

Antiviral Therapy Context

While this question focuses on pain management, remember that antiviral therapy (acyclovir, valacyclovir, or famciclovir) should be initiated within 72 hours of rash onset to reduce acute pain severity and potentially decrease risk of postherpetic neuralgia 10, 8, 5. Pain management is adjunctive to, not a replacement for, appropriate antiviral treatment.

Postherpetic Neuralgia Prevention

• For patients at high risk of developing postherpetic neuralgia (age >60, severe acute pain, extensive rash), consider early initiation of gabapentin or tricyclic antidepressants (amitriptyline 10-25 mg nightly) during the acute phase 11, 5
• Pre-emptive treatment with low-dose tricyclics from diagnosis reduces postherpetic neuralgia incidence by approximately 50% 11