Improving the management of neuropathic pain.

Neuropathic pain is defined as 'pain arising as a direct consequence of a lesion or disease of the somatosensory system'. It may reflect a widespread neuropathic process (e.g. diabetic neuropathy) or a more focal disorder (e.g. post-herpetic neuralgia). The practical importance of recognising neuropathic pain (as distinct from nociceptive pain) lies in the difference in effective treatments. The patient may be experiencing more than one type of pain. Many long-term disabling neurological disorders, such as multiple sclerosis, as well as causing neuropathic pain, may also give rise to musculoskeletal pains which may be more readily amenable to treatment. Most treatment for long-term pain, including neuropathic pain, should be provided in primary care, with specialist support. When taking the history it is important to elicit information about the site, duration, intensity and character of the pain, or pains, and what precipitates and relieves it. Accompanying somatosensory disturbance in the painful territory (numbness; allodynia; hyperalgesia; paraesthesia and dysaesthesia) is strongly suggestive of neuropathic pain. A specialist opinion should be sought where the diagnosis is uncertain, or the patient's condition is rapidly deteriorating or uncontrolled. This may be a specialist in a particular condition, to address issues of primary diagnosis, or a specialist in pain medicine to advise on, or provide, further treatment. Patients who are struggling with their pain are best served by specialist centres that can endeavour to explain the condition and encourage self-management.