A number of treatments are available for the treatment of neuropathic pain. Based on published evidence, the TCAs and gabapentin are first line therapy for the treatment of painful peripheral neuropathies. Carbamazepine is the drug of choice for trigeminal neuralgia and is often useful for the treatment of the paroxysmal, lancinating component of pain in a number of other conditions, including peripheral neuropathies.
Alternative treatments consist of other anticonvulsants, mexilitene, tramadol, or topical agents.
Treatment with opioids should be reserved for patients who have failed other treatment modalities. For most drugs, it is essential to start at a low dose, and to gradually titrate to efficacy. Starting at too high a dose or titrating too quickly can lead to early discontinuation of the drug because of side effects. Apprehension by the patient will make it difficult to reintroduce the drug and a potentially useful treatment modality will be lost. If a patient experiences partial pain relief with one drug as monotherapy, a combination of two or more different class of drugs can often yield better efficacy results.