Nerve pain, also called neuropathic pain, is treated with a combination of oral medications, topical treatments, physical therapy, and lifestyle changes tailored to the underlying cause. Unlike ordinary pain from an injury, nerve pain stems from damage or dysfunction in the nerves themselves, which means standard painkillers like ibuprofen rarely help. The most effective approach almost always involves treating the root cause (like poorly controlled blood sugar) while managing symptoms through one or more therapies.
Why Nerve Pain Requires Different Treatment
Ordinary pain signals travel along healthy nerves to warn you about tissue damage. Nerve pain works differently: the nerves themselves are misfiring, sending pain signals when there’s no injury to react to. This is why nerve pain often feels like burning, electric shocks, stabbing, or tingling rather than the aching or throbbing of a typical injury. It also explains why anti-inflammatory drugs and acetaminophen do little for most people with neuropathic pain.
Effective treatment targets the electrical activity of nerves or the brain’s processing of pain signals. That’s why medications originally developed for seizures and depression turn out to be the most reliable options.
First-Line Medications
Updated treatment recommendations from the Neuropathic Pain Special Interest Group, published in 2025, confirm that two main drug classes remain the standard starting point: anticonvulsants (medications that calm overactive nerve signaling) and certain antidepressants that act on pain pathways. These aren’t prescribed because nerve pain is “in your head.” They work because the same brain chemicals involved in mood, specifically serotonin and norepinephrine, also regulate how pain signals are processed.
Anticonvulsants like gabapentin and pregabalin reduce the intensity of nerve firing. They’re commonly prescribed for diabetic neuropathy, post-surgical nerve pain, and shingles-related pain. Side effects like drowsiness and dizziness are common early on but often improve over a few weeks as your body adjusts. The 2025 guidelines flag an increased risk of harm when pregabalin is combined with opioid medications, so your prescriber should assess that combination carefully.
Older-style antidepressants called tricyclic antidepressants (TCAs) have decades of evidence behind them and remain a recommended first-line option, though they carry more side effects for older adults. Newer antidepressants in the SNRI class tend to be better tolerated. These medications don’t provide instant relief. Most people need several weeks at a therapeutic dose before noticing meaningful improvement, and finding the right medication or combination can take time.
Topical Treatments for Localized Pain
When nerve pain is concentrated in a specific area, such as the feet, a patch of skin after shingles, or a surgical scar, topical treatments can deliver relief with minimal side effects. The 2025 guidelines recommend topical options as second-line treatment generally, but they can be a smart first choice for older adults or anyone taking multiple medications, since so little of the active ingredient reaches the bloodstream.
Lidocaine 5% patches numb the area by blocking nerve signals locally. They’re worn for 12 out of every 24 hours, and only about 3% of the medication enters your system. Side effects are mostly limited to mild skin reactions like redness or itching at the application site. Even when worn for up to 72 hours in safety testing, blood levels stayed well below any concerning threshold.
Capsaicin, the compound that makes chili peppers hot, is available in two forms. Over-the-counter creams (0.025% to 0.1% strength) cost around $8 per ounce but require application up to four times daily, which many people find impractical. The prescription-strength 8% capsaicin patch is far more potent and applied in a clinic, with treatments spaced at least three months apart. The initial application causes a temporary burning sensation and redness, but the patch works by depleting the nerve endings of a chemical they need to transmit pain signals. Over time, this can meaningfully reduce pain in the treated area.
Treating the Underlying Cause
Symptom management matters, but addressing why the nerves are damaged in the first place is what prevents things from getting worse. The cause shapes the entire treatment plan.
Diabetes is the most common culprit behind nerve pain, particularly in the feet and legs. Chronically elevated blood sugar damages the tiny blood vessels that supply peripheral nerves. The American Diabetes Association recommends keeping A1C (a measure of average blood sugar over roughly three months) below 7.0% for most adults, though individual targets vary. Reaching and maintaining that threshold can slow or halt further nerve damage, even if it doesn’t reverse damage that’s already occurred.
Other treatable causes include vitamin B12 deficiency, excessive alcohol use, autoimmune conditions, infections like shingles, and physical compression of nerves (such as carpal tunnel syndrome). When a compressed nerve is the issue, treatment may be as straightforward as a wrist splint, ergonomic changes, or in some cases, a procedure to relieve the pressure.
Physical Therapy and Nerve Gliding
Movement-based therapies play a larger role in nerve pain than many people expect. When nerves become compressed or irritated, they can get “stuck” in surrounding tissues. Nerve gliding and nerve flossing are gentle exercises designed to help irritated nerves slide more freely through the body, reducing tingling, numbness, and pain.
A nerve glide stretches the nerve in one area while easing tension in another. A nerve floss uses a repeated back-and-forth motion to lightly tighten and release the nerve, improving its ability to move without triggering pain. These exercises are especially useful for conditions like carpal tunnel syndrome, sciatica, and cubital tunnel syndrome.
A basic median nerve glide, for example, targets tingling or numbness in the hand and fingers. You stand with your arm relaxed at your side, palm facing forward, then slowly bend your wrist back to stretch the front of the wrist and palm. You repeat this 5 to 15 times per side. Adding a gentle head tilt toward the opposite arm increases the stretch along the full nerve path from neck to fingertips. These exercises should feel like a mild stretch or gentle pulling, never sharp pain. A physical therapist can identify which specific nerves are involved and prescribe the right set of movements.
TENS Units and At-Home Devices
Transcutaneous electrical nerve stimulation (TENS) uses a small battery-powered device to deliver mild electrical pulses through pads placed on the skin. For nerve pain, recommended settings are typically 80 to 120 Hz (pulses per second) at a low pulse width of 50 to 100 microseconds. You should feel a comfortable tingling, not anything painful. Sessions generally last 15 to 30 minutes.
TENS won’t fix the underlying problem, but it can temporarily reduce pain intensity by essentially flooding the nerve pathways with competing signals, making it harder for pain messages to get through. Many people find it helpful as an add-on to other treatments, particularly during flare-ups. Units are widely available without a prescription for $30 to $60.
Supplements That May Help
Alpha-lipoic acid is the supplement with the strongest evidence for nerve pain, particularly diabetic neuropathy. It’s an antioxidant that appears to improve nerve function and reduce symptoms like burning and tingling. A randomized, double-blind trial found that 1,200 mg daily (taken as 600 mg twice a day) for four weeks produced pronounced positive effects with few side effects. It’s available over the counter, though you should be aware that high-quality formulations vary in price and absorbability.
B vitamins, particularly B12, are essential for nerve health. Supplementation helps if you’re deficient but provides little benefit if your levels are already normal. Deficiency is common in older adults, people who take certain acid-reducing medications, and those following a strict plant-based diet.
Acupuncture
Acupuncture has shown promising results in clinical trials for certain types of nerve pain. In a randomized controlled trial of patients with diabetic neuropathy, 12 sessions over 8 weeks led to significant improvement in about 81% of the acupuncture group. The treatment produced a meaningful reduction in overall symptom scores compared to the control group. Acupuncture is generally safe, and for people who haven’t gotten adequate relief from medications or who want to reduce their medication burden, it’s a reasonable option to explore.
Advanced Interventions for Severe Cases
When medications, physical therapy, and other approaches haven’t provided enough relief, more invasive options exist. Botulinum toxin injections (the same compound used in cosmetic procedures) are recommended as a third-line treatment for stubborn peripheral nerve pain. The 2025 guidelines note a large effect size with a good safety profile, though the evidence comes from relatively small studies.
Spinal cord stimulation involves implanting a small device that delivers electrical pulses to the spinal cord, interrupting pain signals before they reach the brain. The most common reason for implantation in the United States is failed back surgery syndrome, where persistent pain continues despite one or more spinal surgeries. It’s also used for complex regional pain syndrome, painful diabetic neuropathy, and certain vascular conditions. Results are variable: some people get substantial, lasting relief while others don’t maintain adequate improvement over time. A trial period with a temporary device is standard before committing to permanent implantation.
Opioid medications, including tramadol, are now firmly recommended as a last resort. The 2025 guidelines restrict all opioids to third-line treatment, to be used only when other reasonable options have failed, for the shortest possible duration, with regular reassessment given the risks of dependence and other harms.