The Neuropathic Pain Treatment Algorithm


What is the algorithm for neuropathic pain treatment?

Neuropathic pain, or nerve pain, is caused when the nervous system is not working properly or becomes damaged. The neuropathic pain treatment algorithm is a guide for primary care physicians and family practitioners to follow when assessing and treating neuropathic pain. It provides recommended steps for a variety of medications and therapies. The algorithm is based on international guidelines, published data, and best practice recommendations.

How it works

The algorithm includes a health care professional obtaining a medical history, performing a physical examination, and interpreting screening tools, such as PainDetect, the Pain Disability Index, and the Leeds Assessment of Neuropathic Symptoms (LANSS). Certain tests may also be ordered, such as a nerve stimulation study or quantitative sensory testing.


Treatment for neuropathic pain begins with first-line therapies. If ineffective, treatment progresses as needed through the sixth-line therapies. Medications and other treatments at each step are listed below.

First-line treatment (four to six-week trial)

  • Non-opioid medications, such as tricyclic antidepressants, serotonin norepinephrine reuptake inhibitors, gabapentinoids, and topical medication, such as lidocaine or capsaicin
  • Multidisciplinary care, such as psychological care, physiotherapy, and massage

Second-Line Treatment (four to six-week trial)

  • Combination therapy of any first-line treatment
  • Tramadol or tapentadol

Third-Line Treatment

  • Referral to a specialist pain clinic
  • Combination therapy of any above treatments
  • Selective serotonin reuptake inhibitors, anticonvulsants, or N-methyl-D-aspartate (NMDA) agonists
  • Interventional therapies, such as epidural injections, pulsed radiofrequency, sympathetic block with local anesthetic, adhesiolysis, radiofrequency denervation

Fourth-Line Treatment (after six months or more of neuropathic pain)

  • Combination therapy of any above treatments
  • Neurostimulation or neuromodulation

Fifth-Line Treatment (four to six-week trial with regular three month review)

  • Combination therapy of any above treatments
  • Low-dose opioids

Sixth-Line Treatment

  • Combination therapy of any above treatments
  • Targeted drug delivery of morphine or ziconotide

As clinical trials for new therapies and medications are completed, successful treatments could be added into, or used to modify, this algorithm in the future.

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