When Nerves Misfire: Understanding and Treating Neuralgia

Neuralgia is a medical term that refers to pain radiating along the course of a nerve or nerves, often sharp, shooting, or electric-shock like in character. It is a subtype of neuropathic pain — that is, pain arising from damage to or dysfunction of the nervous system itself — rather than pain from an external injury or inflammation alone. Because nerves carry signals both to and from the body and the brain, injury or irritation in a nerve can lead not only to abnormal pain signals, but also to changes in sensation (numbness, tingling) or hypersensitivity.

In broad usage, one hears of specific neuralgias such as trigeminal neuralgia (affecting the facial trigeminal nerve), occipital neuralgia (back of the head), glossopharyngeal neuralgia (throat, tongue), intercostal neuralgia (rib-nerve pain), and postherpetic neuralgia (persistent nerve pain after a shingles infection). The general principles of neuralgia apply across these types, though each has its own peculiarities.

Underlying Causes and Mechanisms of Neuralgia

To understand what causes neuralgia, one must look at what can impair a nerve so that it sends abnormal pain signals. In simplest terms, a nerve may be injured, compressed, inflamed, demyelinated, or undergo maladaptive plastic changes. Some of the more common mechanisms include:

Compression from nearby blood vessels, especially in trigeminal neuralgia, can damage the protective covering of nerves, causing erratic firing. Demyelinating diseases like multiple sclerosis expose nerve fibers and disrupt conduction. Viral infections such as shingles can severely irritate nerves and lead to long-lasting pain, while physical trauma from injury or surgery may also cause permanent nerve sensitivity. Metabolic issues like diabetes or toxin exposure can damage nerves gradually. And in some cases, no obvious cause is found — these are classified as idiopathic.

As nerves become hyperexcitable, they may start to send pain signals spontaneously or in response to harmless stimuli. This disordered signaling is often reinforced by changes in the spinal cord and brain, amplifying the pain experience and making it chronic.

How Serious Can Neuralgia Be?

Neuralgia is not typically fatal, but it can seriously affect quality of life. The sudden, stabbing nature of the pain, often triggered by mild stimulation, can be debilitating. In trigeminal neuralgia, even brushing one’s teeth or feeling a breeze on the face can cause excruciating pain. People may avoid everyday activities out of fear of triggering an attack, leading to social isolation, anxiety, and depression.

Chronic pain affects sleep, appetite, mood, and productivity. Over time, the brain may become rewired in response to constant pain, creating a state of central sensitization — a condition in which the nervous system is in a persistent state of high alert. This makes the pain more intense and harder to treat. Left unmanaged, neuralgia can become a serious physical and psychological burden.

What Neuralgia Feels Like

The hallmark of neuralgia is sudden, severe pain in the area served by a nerve. The pain may feel like stabbing, electric shocks, or burning. It often comes and goes in bursts, lasting a few seconds to minutes. In between attacks, there may be a dull ache, tingling, or numbness. Light touch, chewing, speaking, or even smiling can trigger the pain. This trigger sensitivity is a defining feature of neuralgia.

Many sufferers report that the pain is one-sided and follows a specific pattern — for example, across the cheek and jaw in trigeminal neuralgia, or along a rib in intercostal neuralgia. The affected area may feel numb or overly sensitive, and normal sensations may become painful (a symptom known as allodynia).

Can Neuralgia Be Fixed?

The goal in treating neuralgia is twofold: relieve the pain and address the underlying cause, if known. Diagnostic tests such as MRI or nerve conduction studies help identify structural problems or nerve damage. In cases where compression by a blood vessel is involved, surgery may correct the issue.

Most cases of neuralgia are managed with medications that alter nerve signaling. These include anticonvulsants, antidepressants, topical anesthetics, and occasionally, opioids. Non-drug therapies such as nerve blocks, radiofrequency ablation, or neuromodulation may be helpful when medications fail.

Because neuralgia can be complex and difficult to treat, early and aggressive intervention is important. The longer the pain persists, the more likely it is to become chronic and resistant to treatment.

Best Treatments for Neuralgia

There is no universal “best” treatment, as neuralgia differs from person to person. However, certain drugs have become mainstays in clinical practice. For trigeminal neuralgia, the drug of choice is usually carbamazepine, which stabilizes overactive nerve cells. If it is ineffective or causes side effects, alternatives such as oxcarbazepine, baclofen, or lamotrigine may be tried.

For neuralgia related to shingles (postherpetic neuralgia), drugs like gabapentin, pregabalin, or amitriptyline are often used. Topical treatments like lidocaine patches or capsaicin cream can also provide relief.

When medications fail or aren’t tolerated, interventional procedures such as microvascular decompression, gamma knife surgery, or nerve ablation can offer longer-lasting pain control.

Each case requires an individualized approach based on the severity of symptoms, patient tolerance, and underlying pathology.

Neurontin’s Role in Treating Neuralgia

Neurontin, the brand name for gabapentin, is one of the most commonly prescribed medications for neuralgic pain, especially in cases of postherpetic neuralgia and diabetic neuropathy. Originally developed as an anti-seizure drug, gabapentin works by calming overexcited nerves. It binds to calcium channels in the nervous system and reduces the release of neurotransmitters that contribute to pain.

Gabapentin is particularly helpful in reducing burning and shooting pain and is often chosen for its relatively mild side-effect profile compared to other drugs. Drowsiness and dizziness are the most common side effects, especially when starting or increasing the dose.

For trigeminal neuralgia, gabapentin may not be as effective as carbamazepine but is sometimes used in combination with other treatments. It is often better tolerated in older adults and those who cannot handle the side effects of stronger drugs.

Neurontin is usually started at a low dose and gradually increased to avoid side effects. The full effect may take several days or weeks to appear, and doctors often evaluate the patient's response over time before adjusting the treatment plan.

While gabapentin is not a miracle cure, it plays a valuable role in controlling nerve pain for many patients and is considered a first-line therapy in multiple clinical guidelines for neuropathic pain.

The Bigger Picture

Neuralgia is a challenging condition that involves more than just treating pain — it requires understanding the person’s entire nervous system, lifestyle, emotional health, and daily functioning. Success often lies in combining pharmacologic and non-pharmacologic strategies, regular follow-up, and patient education.

The future of neuralgia treatment may include personalized medicine, gene-based therapies, and more advanced neuromodulation techniques that target pain pathways directly. In the meantime, drugs like Neurontin remain vital tools in helping people live better with nerve pain.

With early diagnosis, careful management, and a multidisciplinary approach, many people with neuralgia can experience significant improvement in their symptoms and return to a fuller quality of life.

Drug Description Sources: U.S. National Library of Medicine, Drugs.com, WebMD, Mayo Clinic, RxList.

Reviewed and Referenced By:

Dr. Charles E. Argoff, MD Director of the Comprehensive Pain Center at Albany Medical Center and Professor of Neurology at Albany Medical College. He specializes in neuropathic pain and has authored multiple studies on the use of gabapentinoids like gabapentin in chronic pain management. His clinical research has helped shape modern treatment protocols for trigeminal and postherpetic neuralgia.

Dr. Jennifer L. Hah, MD, MS Assistant Professor of Anesthesiology, Perioperative and Pain Medicine at Stanford University School of Medicine. Her research focuses on optimizing pharmacologic therapy for chronic pain while minimizing opioid dependence. She provides expert insight into the multidisciplinary management of neuralgia and the role of anticonvulsants like gabapentin.

Dr. Jeffrey S. Palmer, MD Neurologist and pain specialist affiliated with Johns Hopkins Medicine. Dr. Palmer has published extensively on the pathophysiology of neuropathic pain and the role of surgical interventions in refractory cases of nerve compression syndromes. He brings key clinical experience in identifying candidates for microvascular decompression and other advanced treatments.

Dr. Anne Louise Oaklander, MD, PhD Associate Professor of Neurology at Harvard Medical School and Director of the Nerve Unit at Massachusetts General Hospital. She is internationally recognized for her research on small-fiber neuropathy and neuralgia syndromes. Her work contributes significantly to understanding the underlying nerve damage mechanisms in conditions like postherpetic neuralgia and idiopathic neuralgias.