Neuralgia: causes, types, symptoms, which can be confused with

Synonyms: sciatica, lumbago (for the sciatic nerve), lumbago (colloquial folk version).

ICD-10 codes:

• unspecified form - M79.2;
• refined are assigned to class G, section "Disorders of individual nerves, nerve roots and plexuses (G50-G59)". Damage to the trigeminal nerve - G50, facial - G51, etc.

Author: Druzhinkina V.Yu., neurologist.
June, 2021.

Neuralgia - damage to a nerve fiber, accompanied by paroxysmal severe pain along its course. It happens in an acute and chronic form. Treatment involves relieving pain, prevention - preventing repeated exposure to factors that led to the development of pathology.

Neuralgia is a term that reflects the involvement of a nerve in a pathological process. It is based on an inflammatory reaction against the background of hypothermia, exposure to microorganisms, compression, trauma.

Neuralgia in women and men is not much different. In women, with irritation of the intercostal nerves, pain is more often localized in the region of the heart, in men - in the hypochondrium.

Prevalence

Neuralgia is quite common in the practice of a neurologist. Examples of prevalence depending on the type of pathology:

• trigeminal nerve - up to 50 patients per 100,000 population, more often in women aged 50–70;
• intercostal - about 12 people per 100,000, characteristic of people of middle and elderly ages.

Neuralgia in the elderly is more common, but this does not mean that middle-aged and young people are not susceptible to the disease.

Differences between neuritis and neuralgia

In medicine, there are 2 concepts similar in sound, but different in meaning - neuritis and neuralgia.

Neuritis is characterized by a deeper lesion of the nerve with affection of the nerve sheath, in which muscle twitching and changes in sensitivity are observed.

Neuralgia is accompanied by the involvement of sensory fibers in the process, therefore pain is always present. Numbness is less common, muscle manifestations are absent

Causes and risk factors

First of all, the following reasons lead to the occurrence of neuralgia:

• diseases of the musculoskeletal system;
• viruses (first of all - herpes, which causes neuralgia after the exacerbation of herpes zoster subsides);
• pinching with tight clothes, crutches;
• hypothermia;
• trauma, sprains;
• tumors;
• diabetes;
• infectious diseases - tuberculosis, brucellosis.

Risk factors that increase the risk of neuralgia:

• diabetes;
• asocial lifestyle;
• age over 50;
• frequent hypothermia.

It is believed that stress and overwork also increase the likelihood of developing the disease.

The lack of treatment for the acute form is the risk of its transition to chronic neuralgia.

Views

There are 3 main classifications of neuralgia.

Due to the occurrence, there are:

• secondary pathology, which is a complication of any process (exacerbation of herpes, trauma)
• primary, arising as an independent disease. Primary is also called idiopathic.

Allocate downstream:

• Acute - lasting up to a month, responds well to therapy, ends in recovery.
• Chronic - the process is delayed, improvement occurs (remission), then the disease resumes. Thus, remissions alternate with exacerbations, usually deterioration occurs under the influence of provoking factors - hypothermia, SARS, wind blowing in the face, etc.
• Severe - a prolonged course of the disease without a noticeable improvement in conditions. Difficult to tolerate by patients.

Also, neuralgia is divided by localization. In fact, the disease can occur wherever the nerves go. The most common types in practice:

• Intercostal neuralgia (she's thoracic or neuralgia of the scapula, lungs in the popular version) - the pain goes along the lower edge of the ribs, it is there that the nerves are located. Often postherpetic or associated with osteochondrosis.
• Femoral nerve - associated with age-related changes in the joints of the legs or with high physical activity, therefore, it is more often manifested in men over 40 years of age and the elderly.
• Pelvic - unpleasant symptoms are localized in the perineum, genitals. Diseases of the genitourinary system, degenerative changes in the spine lead to the development of pathology.
• Trigeminal neuralgia or trigeminal - occurs when the nerve of the same name is involved in the process. At the same time, there are pronounced shooting pains on the face, in the ear, and can affect the scalp. The most common cause of facial pain.
• Facial nerve - usually a neurovascular conflict is the culprit, which is expressed in irritation of the nerve artery. Anatomically, the artery goes close to the nerve, but does not touch it. In case of injuries, tumors on the face, or congenital features, the vessel can twine around the nerve or pinch it. As a result, irritation of the nerve fibers occurs, giving symptoms.
• Occipital - intense sensation located in the back of the head. It is associated with injuries, osteochondrosis, tumors, entrapment of a nerve in the cervical spine. It is characterized by severe headache.
• Sciatic nerve (sciatica) - noted with narrowing of the spinal canal, spasm of the piriformis muscle, injuries, hernia of the spine, lifting weights, sharp turns of the body.
• Solar plexus or solar plexitis (popularly called neuralgia of the abdomen, intestines, esophagus) is an alarming signal that often indicates the involvement of internal organs in the pathological process. It develops with inflammation of the vagus, upper lumbar, celiac nerves. Occurs due to heavy physical exertion, food poisoning, trauma, rupture of the aorta, lymphogranulomatosis, excessive tightening of the belt,
• Neuralgia of the radial, ulnar nerves - appears when the fibers are clamped during sleep, when weights are supported on the forearm, injuries, tumors.
• Nasal nerve (is a branch of the trigeminal nerve) or Charlene's syndrome - manifested by pain in the eyes and nose.
• Pterygopalatine node - develops with a neglected or rapidly proceeding inflammatory process in the sinuses of the skull, facial trauma, caries, periodontitis. It is characterized by pain in the teeth, gums, jaws, eyes, neck. The pain occurs abruptly, more often at night. The attack lasts up to 3 hours, sometimes up to 14 days.
• Neuralgia of the brachial nerve or in the common people of the shoulder - injuries, osteochondrosis, enlarged lymph nodes, tumors, and incorrectly selected crutches are common causes.
• Ear node or ear - the auricle hurts, the skin near it.

A rare type is glossopharyngeal neuralgia. The nerve of the same name is affected. In the area of ​​his innervation - the larynx, ear, lower jaw, pain occurs. There is also a change in taste, salivation.

In popular names, throat neuralgia can be found. Typically, this refers to inflammation of the laryngeal or glossopharyngeal nerve.

Neuralgia of the temporal nerve, which is a branch of the trigeminal nerve, is also rarely observed. It is associated with damage to the parotid gland during surgery, trauma, or after infectious diseases. The patient has increased sweating in the temples and ears.

Symptoms

Neuralgia develops acutely - the patient immediately has pains, sensitivity and motor function may be impaired. With a long course of the disease, muscle atrophy is noted in the affected area.

The localization of pain depends on the innervation zone of the inflamed nerve. All neuralgias are characterized by the appearance of sharp, shooting, burning, unbearable pains. This is due to irritation of sensitive fibers.

With inflammation of the nerves that contain sensory fibers, the patient has a violation of sensitivity.

The options are:

• dysesthesia - a change in perception, for example, tickling feels like pressing or tingling, and hot like cold;
• anesthesia - numbness with loss of pain, tactile, temperature perception;
• hyperesthesia - an excessive sensation of even a small impact, as an example - soreness with a light touch;
• parasthesia - spontaneously arising unpleasant sensations in the form of pain, feeling of crawling creeps (typical of patients with diabetes mellitus).

The characteristic signs of neuralgia are:

• absence of pain in the interictal period;
• increased discomfort when inhaling, coughing (refers to the intercostal type, inflammation of the solar plexus) or touching the skin at the place where the nerve passes (for other options);
• any effect can provoke a new attack - a gust of wind, cold air, brushing teeth, combing hair, accidentally pressing on the nerve points.

Duration of symptoms. The duration of manifestations ranges from a week or two to an indefinite time.

Dyspnoea with neuralgia. By itself, the pathology does not cause shortness of breath, lack of air, but with inflammation of the intercostal nerves or solar plexus, they are observed at the height of pain, especially in elderly patients. Also, with these types, there may be lumbago, burning in the right side.

Heartache. Neuralgia does not cause heart pain, but due to strong unpleasant sensations, existing diseases of the cardiovascular system can be aggravated. This is manifested in an increase in pressure, an attack of angina pectoris.

Irradiation of pain. The pain can be given to the arm, leg, ear, eyes, teeth, chest - those organs and formations, which include the inflamed nerve or its branches. Irradiation to the mammary gland and abdomen is possible. Irritation of the nerves on the face often leads to pain in the teeth.

Numbness. Inflammation in the nerves associated with problems in the cervical spine, often accompanied by numbness of the arm, shoulder; in the lumbar - legs, perineum; in the chest - chest, back, abdomen.

Temperature with neuralgia. With pathology, an increase in temperature can be observed if the cause is infectious, viral diseases (most often - the herpes virus), decaying tumors.

Specific symptoms. Cough with neuralgia is observed with inflammation of the vagus nerve. If the nerves responsible for hearing and salivation are damaged, dry mouth, salivation, and a decrease or distortion of auditory perception are noted.

What can be confused with neuralgia

The severity of pain in neuralgia, their rapid increase make the doctor suspect several other, more serious diagnoses at once. Differential diagnosis is presented in the table:

Sign of another disease	Sign of neuralgia
Myocardial infarction	On the ECG, characteristic changes, often a serious condition, may be vomiting, loss of consciousness, shortness of breath.	There are no changes in the ECG, the pain is not relieved by taking nitroglycerin, there is no shortness of breath, cold clammy sweat.
Angina pectoris	The ECG shows characteristic changes. The pain is relieved by taking nitroglycerin.	There are no changes in the ECG, the pain is not relieved by taking nitroglycerin, it increases with movement, there is no shortness of breath.
Hernia of the esophagus	It occurs after eating, especially overeating, drinking carbonated drinks, mushrooms, corn, smoked foods; when moving to a horizontal position after eating. The diagnosis is confirmed by fluoroscopy of the stomach with barium in the Trendelenburg position, and pathology can also be seen with FDGS.	There is no connection with food intake, EGD and X-ray with barium do not find pathologies.
Osteochondrosis	The pain is more often aching, constant, prolonged. Changes are detected on X-ray, CT or MRI. NSAIDs help well,	Sharp, shooting pains; when examining, changes are not found. NSAIDs help weaker.
Inflammatory processes in the tooth canal	No trigger points, pain when chewing, contact with cold, hot, sour.	There are trigger points. The pressure on the tooth is usually painless.
Pancreatitis	Often, pain is of a girdle nature. There are changes in ultrasound - swelling of the gland, uneven structure. Biochemical indicators (amylase, AST, ALT) are increased. Nausea and vomiting are present.	No changes in ultrasound. Biochemical parameters (amylase, AST, ALT) are normal. No nausea, vomiting.
Cholecystitis, liver disease	There are inflammatory changes on ultrasound. Biochemical parameters (bilirubin, AST, ALT) are increased. Nausea, vomiting, yellowing of the skin, discoloration of the stool, darkening of urine are present.	No changes in ultrasound.
Kidney disease	There are signs of inflammation on ultrasound. In the general analysis of urine, leukocytes, mucus, microorganisms, blood are found. An increase in body temperature is often noted.	There are no changes in ultrasound, in the analysis of urine, tapping on the lumbar region is painless.
Pneumonia	Cough, fever, weakness, shortness of breath are present. Examination reveals pneumonia.	No changes on X-ray, CT.

Survey

Diagnosis of neuralgia is the competence of a neurologist or therapist.

Neuralgia is not confirmed by laboratory or instrumental research methods. In most cases, characteristic seizures allow a diagnosis to be made. To exclude other diseases and confirm inflammation, the doctor may prescribe:

• ECG, chest x-ray, ultrasound of internal organs - when affecting the intercostal nerves, solar plexus;
• general, biochemical blood tests - detect inflammation;
• ENMG (electroneuromyography) - shows the extent of the involvement of the nerve in the process, as well as whether there are disturbances in the conduction of impulses to the muscles.

Treatment

Neuralgia is treated by a neurologist, in his absence - by a therapist.

Neuralgia can be cured, the prognosis is influenced by the timeliness of treatment - the earlier the patient visits a neurologist, the better.

Drugs for the treatment of neuralgia

The main drugs (can be used in the form of injections or tablets, depending on the clinical situation):

• Anticonvulsants - the main active agents, are prescribed to almost all patients in order to relieve pain. Examples - "Finlepsin" (INN - carbamazepine), gabapentin.
• Anti-inflammatory - aimed at relieving the inflammatory response, edema, pain. Prescribed diclofenac (trade name "Voltaren"), ibuprofen (aka "Nurofen"), meloxicam ("Movalis"), nimesil ("Nise"), ketoprofen ("Ketonal"), ketorolac ("Ketorol"). Paracetamol is allowed for pregnant and lactating women.
• Analgesics such as metamizole sodium (aka analgin) are rarely used, mainly with intolerance to anti-inflammatory drugs.
• With severe nerve edema, hormones, such as dexamethasone or prednisolone, may be prescribed in a short course of 3-5 days.
• Muscle relaxants - relax the muscles, thereby reducing the stress on the inflamed nerve. Most often used for neuralgia associated with spinal problems. The drugs are midocalm and sirdalud. In the absence of these funds, "No-shpa" can be used, but with less effect, since its relaxing effect is directed not only to muscles, but also to blood vessels.
• B vitamins. They play a supporting role, improving the functioning of the nerve fiber. According to individual studies, B₂, IN₆ and in₁₂ reduce neuropathic pain. Used "Milgamma", "Combilipen", "Neuromultivit".
• With persistent neuralgia, a blockade is prescribed, for example, with novocaine.

To relieve emotional stress, drugs are prescribed based on mint, motherwort, with severe course - antidepressants (amitriptyline has the ability to reduce neuropathic pain), tranquilizers.

Neuralgia is not treated with antibiotics - there is no microbial component.

Physiotherapy

After the expiration of the acute periods (on the 4th day from the onset of the disease and further), physiotherapy is prescribed according to the state of health and dynamics. In order to relieve inflammation and anesthesia, magnetotherapy is used on the "Almag", "Almag-2" devices. For intercostal neuralgia, Kuznetsov's applicator is used. An important condition is that the procedures should not bring pain to the patient.

Acupuncture takes a special place in the recovery process. Properly performed acupuncture activates the nerve and helps prevent complications. Some neurologists are trained in acupuncture and can carry out such procedures for patients on their own.

With neuralgia of the facial, ulnar, and radial nerves, special exercises are prescribed. For example, puff out your cheeks, rotate your brush, wiggle your fingers, etc. Their task is to restore the work of nerve fibers and muscles in the innervation zone.

ethnoscience

In folk medicine, there is a recipe for iodine with glycerin, but you should not expect a special effect from it, since there is only a superficial effect on a part of the skin above the nerve, and not on the focus itself, plus the causes of the pathology are different - if with trauma such a recipe may still be appropriate, then with an oncological process - no.

In some cases, surgical treatment is used. For example, they separate a nerve and an artery that irritates it, remove bone fragments after injuries, and remove an inflammation focus.

Contraindications for neuralgia

Warming up. It is not recommended to warm the skin and muscles with neuralgia, especially at the onset of the disease. Heat leads to increased edema, the nerve is compressed even more. You shouldn't go to the bathhouse for the same reason. Warming ointments can be used for 3-4 days of illness if hypothermia is the cause. It is not forbidden to make compresses with "Menovazin" for distracting purposes on the painful area - for a short time it is able to slightly reduce pain, but in any case it is not a treatment.

Massage. It is not prescribed for neuralgia - it will aggravate the situation, cause additional pain. But such rehabilitation measures are indicated if the patient begins to develop muscle atrophy with a long-term current pathology. Pepper plaster, mustard plasters - you should not resort to them in case of illness.

Approximate terms of treatment

• for recovery - 1-3 months;
• rehabilitation - 3-6 months.

Complications

In the absence of treatment or with an aggressive course of the disease, the following complications may develop:

• skewed face, uncontrolled salivation, lacrimation or dryness in the eye, impairment or loss of hearing in case of damage to the nerves of the face, head;
• muscle atrophy in the innervation zone;
• transition to a chronic form with subsequent disability.

Forecast

In general, acute neuralgia responds well to therapy. It can take a long time to fully recover, but the disease will go away without consequences.

With the transition to the chronic form, the prognosis worsens, the quality of life suffers - the main task will be to increase the remission time.

Prophylaxis

It is unlikely that it will be possible to prevent the disease by 100%, but it is possible to reduce the risk of its occurrence or exacerbation. Preventive actions:

• avoid hypothermia;
• in winter, in cold winds, wear scarves that cover your face;
• do not sleep in an uncomfortable position, tight clothes;
• choose crutches carefully;
• do exercises for the spine;
• monitor blood sugar levels;
• do not engage in heavy physical work;
• try to avoid traumatic situations;
• visit an immunologist with a low level of immune defense (manifested by frequent acute respiratory viral infections, colds, tonsillitis, shingles);
• if a drunk person fell asleep with his hand under him, then there is a great risk of pinching the nerves - the limb must be positioned freely.

Neuralgia is a serious pathology that is difficult for patients to bear due to the severity and suddenness of attacks of burning pain, sometimes lasting for hours. During treatment, the doctor tries to completely eliminate the disease, to prevent the transition to a chronic form, so it is important to seek medical help as early as possible.