Treatments depend entirely on the type of nerve damage, symptoms, and location. Your doctor will explain how nerve damage is causing your specific symptoms and how to minimize and manage them. You may be able to reduce your medication dose or manage your neuropathy without medications. Definitive treatment can allow for functional recovery over time, as long as the nerve cell itself has not died.
Correcting underlying causes can result in the neuropathy resolving on its own as the nerves recover or regenerate. Nerve health and resistance can be improved by healthy lifestyle habits such as maintaining optimal weight, avoiding toxic exposures, eating a balanced diet, and correcting vitamin deficiencies.
Smoking constricts the blood vessels that supply nutrients to the peripheral nerves and can worsen neuropathic symptoms. Exercise can deliver more blood, oxygen, and nutrients to far-off nerve endings, improve muscle strength, and limit muscle atrophy. Self-care skills in people with diabetes and others who have an impaired ability to feel pain can alleviate symptoms and often create conditions that encourage nerve regeneration. Strict control of blood glucose levels can reduce neuropathic symptoms and help people with diabetic neuropathy avoid further nerve damage.
Inflammatory and autoimmune conditions leading to neuropathy can be controlled using immunosuppressive drugs such as prednisone, cyclosporine, or azathioprine. Plasmapheresis—a procedure in which blood is removed, cleansed of immune system cells and antibodies, and then returned to the body—can help reduce inflammation or suppress immune system activity. Agents such as rituximab that target specific inflammatory cells, large intravenously administered doses of immunoglobulins, and antibodies that alter the immune system, also can suppress abnormal immune system activity.
Improving symptoms
- For motor symptoms, mechanical aids such as hand or foot braces can help reduce physical disability and pain. Orthopedic shoes can improve gait disturbances and help prevent foot injuries. Splints for carpal tunnel problems can help position the wrist to reduce pressure of the compressed nerve and allow it to heal. Some people with severe weakness benefit from tendon transfers or bone fusions to hold their limbs in better position, or to release a nerve compression.
- Autonomic symptoms require detailed management depending on what they are. For example, people with orthostatic hypotension (significant drop in blood pressure when standing quickly) can learn to prevent drops by standing up slowly and taking medications to improve blood pressure swings. Many people use complementary methods and techniques such as acupuncture, massage, herbal medications, and cognitive behavioral or other psychotherapy approaches to cope with neuropathic pain.
- Sensory symptoms, such as neuropathic pain or itching caused by injury to a nerve or nerves, are more difficult to control without medication. Behavioral strategies can help some people to cope with chronic pain as well as depression and anxiety that many may feel following nerve injury.
Medications recommended for chronic neuropathic pain are also used for other medical conditions. Among the most effective are a class of drugs first marketed to treat depression. Nortriptyline and newer serotonin-norepinephrine reuptake inhibitors such as duloxetine hydrochloride modulate pain by increasing the brain's ability to inhibit incoming pain signals.
Another class of medications that quiets nerve cell electrical signaling is also used for epilepsy. Common drugs include gabapentin, pregabalin, and less often topiramate and lamotrigine. Carbamazepine and oxcarbazepine are particularly effective for trigeminal neuralgia, a focal neuropathy of the face.
Local anesthetics and related drugs that block nerve conduction may help when other medications are ineffective or poorly tolerated. Medications put on the skin (topically administered) are generally appealing because they stay near the skin and have fewer unwanted side effects. Lidocaine patches or creams applied to the skin can be helpful for small painful areas, such as localized chronic pain from mononeuropathies such as shingles. Another topical cream is capsaicin, a substance found in hot peppers that can desensitize peripheral pain nerve endings. Doctor-applied patches that contain higher concentrations of capsaicin offer longer term relief from neuropathic pain and itching, but they worsen small-fiber nerve damage. Weak over-the-counter formulations also are available. Lidocaine or longer acting bupivacaine are sometimes given using implanted pumps that deliver tiny quantities to the fluid that bathes the spinal cord, where they can quiet excess firing of pain cells without affecting the rest of the body. Other drugs treat chronic painful neuropathies by calming excess signaling.
Narcotics (opioids) can be used for pain that doesn't respond to other pain-control medications and if disease-improving treatments aren't fully effective. Because pain relievers that contain opioids can lead to dependence and addiction, their use must be closely monitored by a physician. One of the newest drugs approved for treating diabetic neuropathy is tapentadol, which has both opioid activity and norepinephrine-reuptake inhibition activity of an antidepressant.
Surgery is the recommended treatment for some types of neuropathies. Protruding disks (pinched nerve) in the back or neck that compress nerve roots are commonly treated surgically to free the affected nerve root and allow it to heal. Injuries to a single nerve (mononeuropathy) caused by compression, entrapment, or rarely tumors or infections may require surgery to release the nerve compression. Polyneuropathies that involve more scattered nerve damage, such as diabetic neuropathy, are not helped by surgical intervention. Surgeries or interventional procedures that attempt to reduce pain by cutting or injuring nerves are not often effective as they worsen nerve damage and the parts of the peripheral and central nervous system above the cut often continue to generate pain signals (“phantom pain”). More sophisticated and less damaging procedures such as electrically stimulating remaining peripheral nerve fibers or pain-processing areas of the spinal cord or brain have largely replaced these surgeries.
Transcutaneous electrical nerve stimulation (TENS) is a noninvasive intervention used for pain relief in a range of conditions. TENS involves attaching electrodes to the skin at the site of pain or near associated nerves and then administering a gentle electrical current. Although data from controlled clinical trials are not available to broadly establish its efficacy for peripheral neuropathies, in some studies TENS has been shown to improve neuropathic symptoms associated with diabetes.