What Drugs Are Used For Shingles Pain (Postherpetic Neuralgia)?

Thanks for reaching out to us! I'm sorry to hear you haven't found anything over the counter that has helped with the pain you are experiencing after suffering an episode of shingles. This type of pain is referred to as postherpetic neuralgia.

There are several prescription drugs that are FDA-approved and indicated for the treatment of postherpetic neuralgia, and several that aren't FDA approved, but have evidence for benefit and are often recommended by medical guidelines. I won't touch on over-the-counter drugs here (like capsaicin) since you mentioned they have not been effective for you.

Prescription Drugs Used For Shingles Pain

The following prescription drugs are FDA approved for postherpetic neuralgia:

• Neurontin (gabapentin)
• Lyrica (pregabalin)
• Lidocaine

The following drugs aren't FDA-approved specifically for postherpetic neuralgia, but are often used and recommended by medical guidelines:

• Amitriptyline
• Carbamazepine
  
• Desipramine
• Nortriptyline
• Tramadol
• Duloxetine
• Venlafaxine

This answer isn't intended to be a comprehensive guide to all your drug options for the shingles pain you are experiencing, but I'll touch briefly on these drugs in the sections below to help provide some guidance for you! if you would like any additional information, please don't hesitate to reach out.

Gabapentin And Lyrica For Shingles Pain

Let's first start with the two most commonly prescribed drugs for shingles pain, gabapentin and Lyrica.

I lump these two drugs together as they share a similar mechanism of action, even though there are some significant differences between them. Additionally, it is these two drugs (which are classified as gabapentinoids) that are recommended as the first-line therapy by most medical guidelines.

Gabapentin is generally preferred as a starting drug over Lyrica since it is available as a generic, is relatively inexpensive, and has strong positive evidence for benefit. Having said that, it is shorter acting than Lyrica, so you have to dose it more often (three to four times daily versus once to twice daily for Lyrica).

Additionally, gabapentin is often prescribed at a low dose and titrated up to lessen the risk and severity of side effects. Lyrica, while sharing the same side effect profile, tends to be slightly better tolerated, but this will vary by individual. It also doesn't require quite the number of dose adjustments that gabapentin often needs to find the right dose.

Lidocaine For Shingles Pain

Lidocaine is a topical drug that is available both over the counter and as a prescription. It acts as an anesthetic.

Although lidocaine is FDA-approved for shingles pain, there isn't a lot of strong quality evidence showing that it works as well as a lot of the other therapies I talk about here.

Additionally, it can be quite cumbersome to apply lidocaine topically multiple times a day and the effect is only local (i.e. only works where you apply it).

Nevertheless, the drug is relatively inexpensive and can be very effective for smaller affected areas. The 5% patch (i.e. Lidoderm) is most commonly prescribed.

Amitriptyline, Nortriptyline, and Desipramine For Shingles Pain

I lump these drugs together as they are all classified as tricyclic antidepressants or TCAs.

As far as oral therapies go, they are not FDA-approved for treating postherpetic neuralgia but are most often used as a second-line treatment option, after gabapentin/Lyrica.

TCAs are used for a variety of indications, including depression, but most of their use is 'off-label' since they aren't widely prescribed for the treatment of depression anymore due to their side effect profile at higher doses.

They affect a number of neurotransmitters in the brain (e.g. serotonin and norepinephrine) and studies show they are effective for nerve-type pain, like shingles.

They aren't used as a first-line option very often as they tend to have a negative side effect profile compared to gabapentin and Lyrica. They have to be used cautiously in a large percentage of the population as well, including those with heart disease and the elderly. Nevertheless, they represent a great treatment option for many.

Studies show that amitriptyline is likely the most effective of this bunch, but nortriptyline and desipramine tend to be better tolerated.

Carbamazepine For Shingles Pain

Carbamazepine is an anticonvulsant that is sometimes used for shingles pain after initial therapies fail. Like the TCAs, it is not FDA-approved for treating postherpetic neuralgia but is often used. Several other anticonvulsants can be used as well, including valproic acid and oxcarbazepine.

These drugs don't have a lot of evidence for the benefit of shingles type pain specifically but do have a good body of evidence for diabetic neuropathy. They tend to be associated with more side effects than other treatment options.

Cymbalta And Effexor For Shingles Pain

Cymbalta (duloxetine) and Effexor (venlafaxine) are classified as SNRIs (serotonin-norepinephrine reuptake inhibitors). These drugs have become increasingly common as treatment options for any type of nerve pain. They may represent a good treatment option for those suffering from depression as well as dealing with shingles pain.

These drugs do not have the level of evidence that TCA drugs have, but they are generally better tolerated.

Tramadol For Shingles Pain

Tramadol is an opioid drug that is sometimes used for shingles pain. Most commonly, it is started at the same time as other non-opioid therapies, and then slowly discontinued while the others take effect. So, in most cases, it is only a short-term treatment.

Final Words

Thanks again for your question and I hope this answer provided some direction.

There are a lot of options out there, and I highly recommend discussing them with your doctor.

As mentioned, Lyrica and gabapentin are commonly your 'first-line' options, with all the others being alternative options (lidocaine can also be used for small areas as well). Your doctor can help you sort through the best options for you.