From the Guidelines
The workup for nerve pain should begin with a thorough clinical evaluation, including a detailed medical history and comprehensive neurological examination, followed by basic laboratory tests and imaging studies as needed, and treatment should target the underlying cause when possible while managing symptoms with first-line medications such as gabapentinoids, tricyclic antidepressants, or SNRIs, as recommended by the most recent guidelines 1. The clinical evaluation should focus on pain characteristics, such as location, quality, timing, aggravating/relieving factors, and a comprehensive neurological examination to assess sensory, motor, and reflex function.
- Basic laboratory tests should include complete blood count, comprehensive metabolic panel, HbA1c, vitamin B12 levels, and thyroid function tests to rule out common metabolic causes.
- Imaging studies like X-rays, MRI, or CT scans may be necessary depending on suspected etiology.
- Electrodiagnostic studies (EMG/NCS) are valuable for confirming nerve damage and determining its severity and distribution.
- For persistent or complex cases, consider specialized tests such as skin biopsy for small fiber neuropathy, lumbar puncture for inflammatory conditions, or genetic testing for hereditary neuropathies. Treatment should target the underlying cause when possible while managing symptoms.
- First-line medications include gabapentinoids (gabapentin 300-1200mg TID or pregabalin 75-300mg BID), tricyclic antidepressants (amitriptyline 10-75mg at bedtime), or SNRIs (duloxetine 30-60mg daily) 1.
- Topical agents like lidocaine patches or capsaicin cream may provide localized relief with fewer systemic side effects.
- Physical therapy, cognitive behavioral therapy, and complementary approaches can be valuable adjuncts. The workup approach is guided by the understanding that nerve pain results from damage to or dysfunction of the peripheral or central nervous system, requiring both diagnostic precision and multimodal treatment strategies, as supported by recent studies 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Workup for Nerve Pain
- A thorough history and physical examination are necessary to identify characteristic signs and symptoms of neuropathic pain 2
- Laboratory investigations and clinical neurophysiological testing may help identify the underlying etiology and guide treatment selection 2
- Sensory abnormalities are crucial findings leading to a diagnosis of neuropathic pain 3
- The diagnosis of neuropathic pain is made by a careful history and physical examination, with imaging generally not warranted unless red flags are present 4, 5
Diagnostic Tests
- Routine imaging is not recommended for chronic low back pain, but is indicated when red flags are present, there is a neuromuscular deficit, or if pain does not resolve with conservative therapy 5
- Diagnostic tests such as patient history, physical examination, and appropriate diagnostic tests can help assess the severity of neuropathic pain 3
Treatment Selection
- Pharmacotherapy with antidepressants and anticonvulsants represents the cornerstone of medical treatment for neuropathic pain 2, 3
- Nonpharmacologic treatment is first-line management for chronic low back pain and may include therapies such as counseling, exercise therapy, and physical therapy 5
- Pharmacologic interventions are second-line treatment for chronic low back pain, with nonsteroidal anti-inflammatory drugs as the initial medication of choice 5