When patients arrive at the doctor’s office with nerve pain — also known as neuralgia — they don’t always know the culprit behind the pain. But that doesn’t mean their pain can’t be diagnosed and treated.
“There is hope,” says Dr. Deepti Agarwal, director of interventional and integrative pain management and longevity medicine at Case Integrative Health in Chicago. “(Nerve pain is) one of the most challenging diagnoses we encounter.”
What Is Nerve Pain?
Boiled down to the basics, your nerves are integral to feeling any kind of pain, as well as other sensations, which makes diagnosing nerve pain tricky.
“Pain signals are sent to the brain by the nerves. Often, this is due to inflammation or injury in body tissues like the muscles, skin or bones,” explains Dr. Ryan Jacobson, a neuromuscular neurologist at RUSH University Medical Center in Chicago. The pain is deemed either nerve pain or neuropathic pain, which is when that pain is caused by an injury to the nerves themselves.
“Sometimes that can be an injury to one particular nerve, like carpal tunnel syndrome,” Jacobson says. “Other times, it’s a more widespread nerve injury or peripheral neuropathy.” Peripheral neuropathy is a type of nerve damage that impacts the extremities, such as the hands or, most often, the feet.
Nerve pain can also coexist with other medical conditions, such as diabetes, autoimmune diseases, and disorders affecting the muscles, joints, bones and connective tissues, making a diagnosis even more challenging, Agarwal adds.
Symptoms of Nerve Pain
Nerve pain can have unique symptoms — which helps with a diagnosis — and may present as a variety of sensations.
“Patients describe these as numbness, pins-and-needles, tingling, burning or even ‘electric shocks,'” Agarwal explains.
For some patients, the pain is constant, she adds. For others, it comes and goes. Pain may also feel more aggressive when you’re lying down, and it can worsen at night, impacting sleep.
Patients may also describe or experience:
— Ice-cold sensation.
— Sensitivity to touch.
— Reduced deep tendon reflexes.
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Diagnosing Nerve Pain
To explore the cause, doctors ask about symptoms, take a thorough medical history and examine the patient. This approach takes into account everything from sensory loss to abnormalities.
For example, says Dr. Eva Feldman, a professor of neurology at the University of Michigan in Ann Arbor, “a physician may test a patient for sensory loss using, among other means, a pinprick. If the patient doesn’t feel that and other things like a cotton wisp or tuning fork on the big toe, foot or ankle, that may point to the presence of neuropathy.”
Where in the body a person is experiencing the pain, whether it’s local or more generalized — “all over” — is also relevant. For instance, certain conditions, such as diabetes, can cause nerve pain in the legs, hands and feet, and some drug treatments, such as chemotherapy, can damage nerves in the limbs.
Certain sports injuries can cause nerve pain as well, such as a “stinger,” which involves a bundle of nerves between the neck and spine called the brachial plexus. Conversely, nerve injury or trauma can lead to rare disorders like complex regional pain syndrome.
Other causes of nerve pain can include:
— Vasculitis, which is an inflammation of the blood vessels.
— Vitamin deficiencies.
— Lyme disease.
— Certain medications.
— Environmental exposure to heavy metals, organic solvents or mold.
— Heavy alcohol use.
During the exam, a physician may also conduct testing, including bloodwork, to better understand what’s behind the pain. This may include a test called a hemoglobin A1c to check your average blood sugar levels to see if you may have diabetes or be at risk for it. Your doctor may also check if your vitamin B12 level is low, which can cause nerve dysfunction and numbness.
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Do I Need an EMG Test?
One test that’s worth asking about, Jacobson says, is an EMG, or electromyogram. This is “an electrical test, which is useful for detecting injury to the peripheral nerves,” he explains. The peripheral nerves are located outside the brain and spinal cord.
An EMG can help in multiple ways. First, it may help narrow down whether the pain is related to the injury of a specific nerve or nerve root or if it relates more broadly to all the nerves, as with peripheral neuropathy. It can also help physicians assess the health of nerves, diagnose the cause of nerve pain and determine what other tests might be needed if the cause still isn’t clear.
An EMG test involves inserting small needles with electrodes into muscles to detect electrical signals given off by the muscle. It can be uncomfortable. However, doctors say most patients are able to tolerate it, though it’s important to let your doctor know if you’re experiencing significant pain during or after the procedure. This test generally takes around an hour, but it can be as short as 30 minutes or as long as 90 minutes.
Both EMG testing and nerve conduction studies can show how the body’s electrical signals are traveling. According to MedlinePlus, an EMG test measures the signals muscles make when they are resting versus when they are being used. In contrast, a nerve conduction study measures how fast the signals travel.
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Should I See a Neurologist?
Experts generally recommend starting with your primary care doctor if you think you’re experiencing nerve pain. Many patients may also need to see a neurologist — a doctor who specializes in muscles and nerves — to determine the cause of nerve pain.
For example, if the initial bloodwork of your vitamin B12 level and hemoglobin A1c for diabetes comes back normal, and another common cause of neuropathy isn’t to blame, further investigation may be needed to determine the cause of the nerve pain. If that’s the case, “we can talk about more extensive testing,” says Dr. Andrew Dorsch, a neurologist at RUSH University Medical Center. Once the source of the pain is better understood, the neurologist can provide treatment options.
Further tests would depend on the person’s symptoms and their risk factors for different conditions. The next level of tests might include screening for autoimmune diseases or inflammatory diseases, looking at hormone function or identifying other metabolic and nutritional markers. Other advanced tests may include imaging, genetic testing or a nerve biopsy.
One reason to see a neurologist — also called a nerve doctor, a specialist with ample experience treating patients with nerve pain — is to avoid unnecessary tests. “Sometimes seeing a neurologist to listen to the symptoms and do an exam can help narrow down the testing quite a bit,” Jacobson says.
Diabetes and Nerve Pain
The leading cause of nerve pain today — and specifically chronic peripheral neuropathy — is diabetes. High blood sugar levels can cause nerve damage, undermining the nerves’ ability to send signals and function properly.
“At least half of individuals with diabetes have neuropathy,” says Feldman.
Those with high blood sugar that isn’t yet full-blown diabetes but instead the precursor, prediabetes, also have an elevated risk.
“About 30% of people with prediabetes have neuropathy,” Feldman adds.
Today, more than 37 million adults in the U.S. have diabetes, which translates to about 1 in 10 Americans, according to the Centers for Disease Control and Prevention.
Treatment for Nerve Pain
The most effective treatment for nerve-related pain includes:
— Physical therapy and exercise.
— Alternative treatments.
— Lifestyle changes.
Medication for nerve pain
For some patients whose symptoms affect their quality of life and function, taking daily medication to reduce their levels of pain may be effective.
“There are a number of different medications that are useful for nerve pain or neuropathic pain,” Jacobson says. “Most of those medications were invented or developed for other purposes first, such as epilepsy or mood.” Besides anticonvulsants and antidepressants, pain relievers may also help.
Ask your doctor, too, how long it may take for medication to be effective. “Many of the medications are effective within a few days,” Jacobson says. “Others take many days or weeks to have an effect. Often a slow increase in the dose is needed.”
You should check on any risks associated with medication as well.
“The specific side effects will depend on which medication is chosen,” Jacobson explains. “As all of these medications work on the nervous system, some amount of sedation or fatigue are fairly common side effects to several of the medications that are considered.”
Physical therapy and exercise
Staying active and following a prescribed exercise regimen may help to ease nerve pain. Home exercises, for instance, such as sciatica or arm pain exercises, may be effective, depending on where you have nerve pain.
Another example: For neuropathy, moderate aerobic activity for 150 minutes per week, after getting clearance from or under the supervision of a physician, can be beneficial. “This can include activities such as brisk walking — at least 2.5 miles per hour — swimming or biking less than 10 miles per hour,” Feldman says.
Others with radiculopathy — or pain due to a compressed or pinched nerve in the spine — may be able to relieve symptoms with physical therapy. “This physical therapy focuses on the area of the pain with specific exercises for the neck or back done under the supervision of a physical therapist,” Feldman notes. For example, you might do a controlled head turn or neck bend for a pinched nerve in the neck.
“Physical activity in general is often helpful. Often, exercise can improve symptoms,” Jacobson adds. He notes that it can also be preventive by staving off conditions like diabetes that can cause nerve pain.
Depending on the type of nerve pain that you’re experiencing, there are many different approaches that may treat your pain.
For instance, acupuncture is often recommended for treating neuropathy, and some patients have reported pain relief. However, the data is somewhat limited regarding this therapy, which involves inserting thin needles into the body at strategic points for nerve pain. A 2017 Cochrane analysis of available research found there isn’t enough to support or refute acupuncture for neuropathic pain. However, a 2022 review in Frontiers of Neuroscience argued that acupuncture provides an “alternative or adjunctive therapy for neuropathic pain.”
Given the myriad options offered for nerve pain, experts recommend first talking to your doctor about any approach you’re considering to manage your pain. It’s important to determine upfront what evidence might support any suggested treatment as well as any potential risks. It’s also important to check with your insurance plan to see what coverage you have for both traditional and alternative therapies.
Lifestyle changes, again depending on the cause of the pain, may be able to lessen the pain.
For example, properly managing diabetes is key to preventing diabetic neuropathy. That’s all the more important given how many people with chronic conditions suffer from nerve pain. “It’s a very common, prevalent problem in a very common, prevalent disease,” Feldman reiterates.
Experts emphasize the critical importance of also addressing prediabetes to prevent diabetes and reduce the risk of nerve damage. That means making sure to follow recommended lifestyle changes, such as eating a healthy diet, exercising regularly and losing weight.
In general, paying attention to the three pillars of health — sleep, diet and exercise — can be helpful in lessening discomfort.
When the Cause Isn’t Clear
Although symptoms of nerve pain may be readily distinguishable from other types of pain, frequently it’s not so simple to zero in on the exact cause of that nerve pain.
In some cases, the cause is never known, so it’s important to have a frank discussion about additional medical visits or testing.
“It is not uncommon that we have to monitor patients to determine the cause,” says Dr. Suraj Muley, a neurologist and medical director of neuroimmunology at the Bob Bove Neuroscience Institute at HonorHealth in Arizona. If the cause of the nerve problem isn’t obvious initially, he suggests following up with a visit to the neurologist every three to six months.
Your doctor may also advise that you try a combination of medications, a TENS unit or even injections to ease the pain. Staying connected with your primary care provider, neurologist or a pain management provider can help you find the regimen that works best for you and protects your quality of life.
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Update 04/24/23: This story was previously published at an earlier date and has been updated with new information.