Medication for Pain Associated with Shingles
For acute herpes zoster pain, start controlled-release oxycodone immediately alongside antiviral therapy, as it provides significant pain relief during the first 1-2 weeks when pain is most severe, while gabapentin should be reserved for post-herpetic neuralgia rather than acute pain. 1
Acute Herpes Zoster Pain Management
Antiviral Therapy (Foundation of Treatment)
- Initiate antiviral therapy within 72 hours of rash onset to reduce severity and duration of acute pain, using famciclovir, valacyclovir, or high-dose acyclovir 2, 3, 4
- All three antivirals are equally effective, shortening viral shedding and healing time by 1-2 days, with famciclovir and valacyclovir offering more convenient three-times-daily dosing versus acyclovir's five-times-daily schedule 4, 5
- Brivudine 125mg once daily is as effective as famciclovir 250mg three times daily and particularly advantageous for elderly patients already taking multiple medications 5
Acute Pain Control
- Controlled-release oxycodone significantly reduces mean worst pain over days 1-8 (p=0.01) and days 1-14 (p=0.02) compared to placebo, though constipation causes treatment discontinuation in 27.6% of patients 1
- Gabapentin does not provide significantly greater pain relief than placebo for acute herpes zoster pain, with data only suggesting modest benefit in the first week 1
- Corticosteroids added to antiviral therapy provide modest benefits in reducing acute pain intensity, though this remains somewhat controversial 2
Important Caveat
- The most recent high-quality randomized controlled trial demonstrates gabapentin's ineffectiveness for acute zoster pain, contradicting older recommendations that suggested early gabapentin initiation 1, 3
Post-Herpetic Neuralgia (PHN) Management
First-Line Treatments
- Gabapentin is the first-line oral pharmacological treatment for PHN, starting at 300mg day 1, 600mg day 2, 900mg day 3, then titrating to 1800-3600mg/day with no additional benefit above 1800mg/day 6
- Tricyclic antidepressants have excellent efficacy (NNT = 2.64), with nortriptyline strongly preferred over amitriptyline due to better tolerability and equivalent analgesic benefit 6, 7, 3
- Topical lidocaine 5% patches provide excellent efficacy (NNT = 2) with minimal systemic absorption, making them particularly suitable for elderly patients or those with comorbidities 6
- Capsaicin 8% dermal patch provides pain relief for at least 12 weeks after single application, though erythema and pain are common; apply 4% lidocaine for 60 minutes before capsaicin to mitigate side effects 6
Second-Line Treatments
- Pregabalin (NNT = 4.93) if inadequate response to gabapentin, with effective doses of 150-600mg/day in two divided doses 6
- Opioids (oxycodone, extended-release morphine, methadone) show efficacy (NNT = 2.67) but should not be first-line due to risks of pronociception, cognitive impairment, respiratory depression, endocrine/immunological changes, and addiction potential 6
- Tramadol shows efficacy (NNT = 4.76) 6
- Combination therapy (morphine with gabapentin) may be more effective when single agents fail, allowing lower doses of each medication 6
Critical Pitfalls to Avoid
- Do NOT use lamotrigine for PHN due to lack of efficacy evidence and risk of serious rash 6
- Do NOT use corticosteroids for established PHN as they provide no benefit and expose patients to hyperglycemia, osteoporosis, hypertension, and immunosuppression 6
- Monitor for somnolence, dizziness, and mental clouding with gabapentinoids, especially in elderly patients, as these are major fall risk factors 6
- PHN management follows the same guidelines as other neuropathic pain conditions 8