Recommended treatments

• The use of simple analgesia (paracetamol alone or in combination with codeine) is recommended in two guidelines on the management of shingles and post-herpetic neuralgia [BSSI, 1995; International Herpes Management Forum, 2002]. These drugs are commonly used, although CKS could find no good-quality evidence to support this.
• The recommendation to offer a trial course of amitriptyline or pregabalin (or gabapentin if there is a local decision to prefer gabapentin over pregabalin) is based on guidance issued by the National Institute for Health and Clinical Excellence on drug treatment of neuropathic pain in adults [NICE, 2010]. For further information, see the CKS topic on Neuropathic pain - drug treatment.
• Having reviewed the evidence for a number of neuropathic conditions (including post-herpetic neuralgia), the NICE guidance development group (GDG) treated the term 'neuropathic pain' as a blanket condition regardless of the underlying cause; the GDG considered this to be helpful and practical for non-specialist healthcare professionals and patients. However, condition-specific recommendations were made if robust evidence on clinical efficacy and cost-effectiveness existed (as in the case of painful diabetic neuropathy), or where the evidence was clearly uncertain and insufficient to alter current clinical practice (as in the case of trigeminal neuralgia). The GDG acknowledged that evidence for treating a particular neuropathic pain condition with a particular aetiology is often extrapolated to other neuropathic pain conditions with other aetiologies, although there is little evidence to support the validity of this [NICE, 2010].

Treatments not recommended

• A review by the International Herpes Management Forum found no evidence to support the use of nonsteroidal anti-inflammatory drugs in post-herpetic neuralgia [International Herpes Management Forum, 2002].
• Carbamazepine has evidence to support its use for neuropathic pain [Wiffen et al, 2005]. However, taking into account the lack of good-quality evidence specific to post-herpetic neuralgia, potentially serious adverse effects, and the lack of a license for this purpose, CKS has not recommended it as primary care treatment.
• CKS has not recommended strong opioids as an option in primary care even though limited evidence suggests they may be effective in reducing the pain associated with post-herpetic neuralgia [Wareham, 2006]. This is in view of their adverse effects profile and the fact that they are more commonly used in a specialist setting [International Herpes Management Forum, 2002].