Postherpetic neuralgia (PHN) is chronic nerve pain that persists long after the rash of a shingles (herpes zoster) outbreak has healed. This neuropathic pain arises because the varicella-zoster virus damages the nerve fibers, causing them to send pain signals to the brain. Since the pain originates from damaged nerves rather than typical tissue injury, common over-the-counter pain relievers are ineffective. Specialized medical care is necessary to manage the burning, stabbing, or aching sensations of PHN.
Initial Medical Contact Points
The initial medical journey for patients with PHN typically begins with their Primary Care Physician (PCP). The PCP is often the first to diagnose shingles and initiates early antiviral treatment, which may reduce the risk of developing PHN. Once the shingles rash resolves, the PCP confirms the acute infection has passed and rules out other causes of persistent pain, such as an ongoing infection.
The PCP begins the first line of pharmacological treatment for the neuropathic pain, which involves prescribing topical agents like lidocaine patches or capsaicin cream. If these basic treatments are insufficient, the PCP may transition the patient to oral medications, such as gabapentinoids or certain antidepressants. However, for complex or refractory cases, the PCP’s primary role shifts to that of a coordinator, referring the patient to specialists for more comprehensive pain management. Dermatologists may also be involved early on, especially regarding the skin rash. They help confirm the PHN diagnosis after the skin lesions clear and assess any residual skin damage or scarring caused by the initial viral outbreak.
Neurological Experts for Chronic Pain
For patients whose pain does not respond adequately to first-line treatments, a consultation with a Neurologist is necessary. Neurologists are medical doctors specializing in disorders of the nervous system, which includes the nerve damage underlying PHN. Their expertise focuses on the pathology of the damaged peripheral nerves and the resulting pain signaling.
The neurologist assesses nerve dysfunction through detailed neurological examinations, which include sensory testing to identify areas of allodynia—pain caused by a non-painful stimulus like light touch. They manage complex medication regimens to quiet overactive nerve signals. This involves titrating doses of anticonvulsant medications, such as gabapentin or pregabalin, which stabilize electrical activity in the damaged nerves. Neurologists also prescribe certain classes of antidepressants, like tricyclic antidepressants (e.g., nortriptyline) or serotonin-norepinephrine reuptake inhibitors (e.g., duloxetine). These drugs are used not for mood issues, but because they modulate neurochemicals that suppress pain. Managing side effects, like dizziness or dry mouth, is a significant part of the neurologist’s long-term strategy.
Advanced Interventional Pain Specialists
When oral and topical medications fail to provide sufficient relief, the patient is referred to an Advanced Interventional Pain Specialist. These specialists are often Anesthesiologists or Physical Medicine and Rehabilitation doctors with specialized fellowship training in pain management. Their focus is on procedural and minimally invasive techniques that target the pain signals along the nerve pathway.
A common intervention is the use of nerve blocks, which involve injecting a local anesthetic near the affected nerves to temporarily interrupt pain transmission. Specific procedures include intercostal nerve blocks for pain on the chest wall or stellate ganglion blocks for PHN affecting the head, neck, or upper extremities.
For more persistent pain, the specialist may employ pulsed radiofrequency (PRF) treatment. This delivers electrical current to the dorsal root ganglion (DRG)—a cluster of nerve cells near the spinal cord—to modulate pain signals without causing permanent nerve destruction. In cases of severe, refractory pain, advanced options like Spinal Cord Stimulation (SCS) or Peripheral Nerve Stimulation (PNS) may be considered. These implanted devices use low-voltage electrical impulses to disrupt pain signals before they reach the brain, often requiring a trial period to ensure efficacy before permanent placement.
Understanding the Multidisciplinary Team
Management of PHN rarely relies on a single professional or treatment, requiring a coordinated approach involving multiple specialists. This multidisciplinary team structure addresses the complex physical and psychological burdens of chronic neuropathic pain. The primary treating physician, whether a Neurologist or Pain Specialist, orchestrates the care plan and ensures seamless communication between all providers.
Pain Psychologists help patients develop coping mechanisms for living with persistent pain and managing associated issues like anxiety, depression, and sleep disturbance. Physical Therapists may also be included in the team when the pain limits mobility or function, helping to maintain strength and flexibility. This coordinated care, which may also involve a physiatrist, recognizes that PHN is a holistic problem, requiring input from various specialties for the most optimal long-term outcomes.