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Neuralgias

Red flags

Refer to alternate diagnostic services.

  • Unexplained weight loss
  • History or suspicion of malignancy

The following may lead to more urgent PPMS categorisation

  • Severe symptoms despite optimum management
  • Escalating opioid dependency

Consider referring this condition to Neurology if the cause is not yet determined.

Neuralgia is a pain syndrome that causes dysaesthesia (often described as lancinating, stabbing or burning) associated with a damaged nerve. The damage can be caused by direct trauma, degeneration (diabetes, MS), vascular insufficiency, autoimmune disease or infection (commonly herpes virus related). It is more common and is more problematic to treat in older people. Identification of an underlying cause is important as this will often determine the best treatment.

Conditions commonly referred in this category are:

  • Trigeminal neuralgia
  • Glossopharyngeal neuralgia
  • Post herpetic neuralgia
  • Occipital neuralgia
  • Multiple sclerosis related
  • Diabetes related (see peripheral neuropathies)
  • Less common causes
    • Chronic kidney disease
    • Porphyria
    • Medication related (cisplatin, paclitaxel, vincristine etc)

Other important information for referring practitioners

Lifestyle changes

  • Encourage healthy activity within pain limits
    • Consider physio referral
    • Hydrotherapy
    • Desensitisation massage
  • Ensure adequate sleep
  • Check for mood disturbances and relationship difficulties
    • Consider psychology referral for any mood disturbances and assistance with pain control

Medical management

  • Optimise medical management of any predisposing secondary condition (if present)
  • Set realistic goals
  • Treat associated mood disorders
  • Avoid over-reliance of medication, encourage self-management and set realistic goals for treatment
    • Target most troublesome symptoms first
    • Consider nerve blocking procedure if single nerve involvement
    • Start at low dose and titrate
    • Agree on trial period for medication.

Current medications used in neuralgia are:

  • Amitriptyline:
    • start at 10mg and slowly escalate dose (this may take weeks)
    • max dose 75-100mg
    • consider nortriptyline in older patients
    • anti-cholinergic effects on bladder can be troublesome in elderly males
  • Tramadol +/- paracetamol:
    • potential synergistic effect
  • Duloxetine:
    • PBS approved for neuropathic pain and major depressive disorder
  • Pregabalin:
    • PBS restricted for neuropathic pain refractory to treatment with other drugs
  • Carbamazepine (used primarily for trigeminal neuralgia and post herpetic neuralgia)

Try to avoid opioid medication. Only use opioid medication for exacerbations and set time limits on prescribing

Referral requirements

A referral may be rejected without the following information.

Essential referral information

  • Persistent Pain Management Service eReferral form
  • Reason for referral
    • Management plan
    • Specific concerns re medication overuse/dependence
    • Need for focussed multidisciplinary approach
  • History of condition
    • Date of onset and timeline
    • Suspected cause of neuralgia
    • Management of condition including predisposing condition if secondary.
    • Treatments trialled and reasons for failure
    • Include relevant specialist letters
  • Current and previous relevant medical conditions
  • List any forensic or ongoing medicolegal issues
  • Current medications and past medication if trialled for neuralgia
  • List drug dependencies, inappropriate drug use and prescribed drug misuse e.g. nicotine, alcohol, cannabis, opioids
  • Allergies
  • Relevant examination findings
    • Plot sensory symptom distribution
    • Look for patterns of involvement (single nerve (entrapment), glove/stocking etc)
  • Investigations
    • Blood investigations relevant to cause and co-morbidities
    • Relevant imaging

Additional referral information (useful for processing the referral)

  • Preferably patient to complete entry patient questionnaire prior to first consultation
  • Investigations related to co-morbidities e.g. diabetic control
  • Relevant imaging
  • Nerve conduction studies

Out of catchment!

Metro North Health is responsible for providing public health services to the people who reside within its boundaries. Special consideration is made for patients requiring tertiary care or services that are not provided by their local Hospital and Health Service. If your patient lives outside the Metro North Health area and you wish to refer them to one of our services, inclusion of information regarding their particular medical and social factors will assist with the triaging of your referral.

  • Impact on employment
  • Impact on education
  • Impact on home
  • Impact on activities of daily living
  • Impact on ability to care for others
  • Impact on personal frailty or safety
  • Identifies as Aboriginal and/or Torres Strait Islander

  • To establish a diagnosis
  • For treatment or intervention
  • For advice and management
  • For specialist to take over management
  • Reassurance for GP/second opinion
  • For a specified test/investigation the GP can’t order, or the patient can’t afford or access
  • Reassurance for the patient/family
  • For other reason (e.g. rapidly accelerating disease progression)
  • Clinical judgement indicates a referral for specialist review is necessary

  • Presenting symptoms (evolution and duration)
  • Physical findings
  • Details of previous treatment (including systemic and topical medications prescribed) including the course and outcome of the treatment
  • Body mass index (BMI)
  • Details of any associated medical conditions which may affect the condition or its treatment (e.g. diabetes), noting these must be stable and controlled prior to referral
  • Current medications and dosages
  • Drug allergies
  • Alcohol, tobacco and other drugs use

  • Full name (including aliases)
  • Date of birth
  • Residential and postal address
  • Telephone contact number/s – home, mobile and alternative
  • Medicare number (where eligible)
  • Name of the parent or caregiver (if appropriate)
  • Preferred language and interpreter requirements
  • Identifies as Aboriginal and/or Torres Strait Islander

  • Full name
  • Full address
  • Contact details – telephone, fax, email
  • Provider number
  • Date of referral
  • Signature

  • Willingness to have surgery (where surgery is a likely intervention)
  • Choice to be treated as a public or private patient
  • Compensable status (e.g. DVA, Work Cover, Motor Vehicle Insurance, etc.)
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