What are the recommended pain medications for herpes zoster?

Pain Management for Herpes Zoster

For acute herpes zoster pain, initiate oral analgesics alongside antiviral therapy, with gabapentin or pregabalin as first-line agents for moderate-to-severe pain, while reserving topical therapies for localized, milder pain after lesions have crusted. 1, 2

Acute Pain Management During Active Herpes Zoster

First-Line Systemic Analgesics

• Gabapentin is the preferred first-line agent for moderate-to-severe acute zoster pain, with early initiation (within 72 hours of rash onset) recommended for patients at high risk of developing postherpetic neuralgia (PHN). 2

• Pregabalin offers comparable efficacy to gabapentin with potentially better tolerability and less frequent dosing requirements. 2, 3

• Start gabapentin or pregabalin early during the acute phase, particularly in elderly patients, those with severe rash, or those experiencing severe prodromal pain—all risk factors for PHN development. 2, 4

Second-Line Systemic Options

• Tricyclic antidepressants (amitriptyline, nortriptyline, desipramine) can be initiated early for patients at high risk of PHN, though they carry higher risk of anticholinergic side effects, particularly in elderly patients. 2, 3

• Opioid analgesics (tramadol, morphine, oxycodone, methadone) should be reserved for severe pain unresponsive to anticonvulsants or tricyclics, given their adverse effect profile and abuse potential. 2, 3

• Acetaminophen/paracetamol and NSAIDs provide mild-to-moderate pain relief and can be used as adjunctive therapy, though they are generally insufficient as monotherapy for severe zoster pain. 4

Topical Therapies

• Topical anesthetics provide minimal benefit during the acute vesicular phase and are not recommended as primary therapy for acute zoster pain management. 1

• Reserve topical lidocaine patches and capsaicin for the post-crusting phase or for established PHN, not during active vesicular eruption. 1, 2, 3

Critical Timing Considerations

• Pain management should be initiated within 72 hours of rash onset alongside antiviral therapy to maximize effectiveness in reducing acute pain severity and PHN risk. 1, 2, 5

• Early intervention with gabapentin or amitriptyline after herpes zoster onset is specifically suggested for patients at high risk of developing PHN (elderly, severe prodrome, severe rash, female sex). 2, 4

Corticosteroids: Limited Role

• Corticosteroids added to antivirals may provide short-term pain relief during acute zoster but carry significant risks (particularly in elderly patients) and do not prevent PHN. 3

• Avoid corticosteroids in immunocompromised patients, those with poorly controlled diabetes, severe osteoporosis, or history of steroid-induced complications. 1

Postherpetic Neuralgia Management

If PHN develops (pain persisting >3 months after rash healing):

• Gabapentin and pregabalin remain first-line systemic agents for established PHN, with FDA approval and robust evidence for efficacy. 6, 2, 3

• Topical lidocaine 5% patches become highly effective for localized PHN after complete lesion healing. 2, 3

• Capsaicin cream can be considered for localized PHN, though initial application may cause burning sensation. 2, 3

• Tricyclic antidepressants (amitriptyline, nortriptyline, desipramine) offer moderate pain relief but require careful monitoring for anticholinergic effects. 2, 3

• Opioids should be reserved for refractory cases, with consultation from pain management specialists for treatment-resistant PHN. 2, 3

Common Pitfalls

• Do not rely solely on topical anesthetics during acute vesicular phase—they are ineffective as primary therapy and delay appropriate systemic pain management. 1

• Do not wait for PHN to develop before initiating gabapentin or tricyclics in high-risk patients—early initiation during acute zoster may prevent PHN. 2

• Do not use corticosteroids routinely—benefits for acute pain are modest and do not outweigh risks, especially in elderly or immunocompromised patients. 1, 3

• Pain management is most effective when combined with appropriate antiviral therapy (valacyclovir 1g TID or famciclovir 500mg TID) initiated within 72 hours of rash onset. 1, 5, 7