Understanding Nerve Pain

By Mary Carpenter

SENSATIONS in the palm of her hand of painful burning—so hot she could feel it with her other hand—woke DC-area writer C.W. several times a night. While C.W. also had neck and shoulder discomfort, this sleep-interrupting pain—accompanied by intense prickling—could range from mild pins-and-needles like feet going to sleep to those of an electric shock. Changing sleep position sometimes helped, but traveling or even a night at the theater made the attacks return for nights afterwards.

A strong pins-and-needles sensation can be nerve pain that indicates risk of permanent nerve damage. But distinguishing inconsequential discomfort from more risky pain can be difficult.  It can be hard to figure out whether pain comes from injured nerves or begins in joints, ligaments and bones—which in turn leads to questions about when to seek medical help and what kind of doctor might respond best to odd complaints, such as a middle-of-the-night very hot hand.

Neuropathic pain rarely responds to NSAIDS—one clue that pain is coming from nerves. The alternative sources—bones or joints— produce “pain messages that are carried along healthy nerves from damaged tissue (for example, a fall or cut, or arthritic knee),” according to researchers in Taiwan and Oxford. The few studies comparing drugs for neuropathic pain found “no difference between NSAIDs and placebo in terms of pain or adverse effects.”

Different sensations during activity can also help distinguish sources of pain. Pain from damaged nerves is “typically a burning or stinging sensation that may be isolated or may spread to different parts of the body…may be accompanied by loss of strength, coordination, or sensation,” according to Sharecare. Joint and bone pain, by contrast, “can be sharp, dull, pressure or throbbing.”

“Pain is the main reason people go to a doctor,” according to NIH Heal Initiative. But “a diverse set of medical conditions is a difficult target to hit…because pain is a lived experience affected by biology…psychology…and cultural expectations (such as the urge by some to just “tough it out”).

The newest drugs in the pipeline for chronic pain focus on neuropathic pain, including one now called VX-548, being tested for radiculopathy (damage to nerve roots) and diabetic peripheral neuropathy. According to the New York Times, among the current options for nerve pain relief, NSAIDs like ibuprofen and Cox-2 inhibitors are “not very effective,” and opioids can be addictive.

Another hopeful nerve-pain drug is low-dose naltrexone (LDN), which can “mitigate the chronic inflammation and central sensitization of neuropathic pain,” according to the American Society of Regional Anesthesia and Pain Medicine (ASRA). But relief of symptoms with LDN can take months, and most insurance does not yet cover the cost.

Meanwhile, demand for ketamine—a drug for which pain is the number one condition for prescriptions—has soared more than 500% since 2017, according to APNews. For ketamine, however, the psychedelic effect—which many patients wish to avoid—may be essential for pain relief. Said L.A.’s Ketamine Healing Clinic owner David Mahjoubi, “We want patients to dissociate or feel separate from their pain…”

C.W. visited a physiatrist (M.D. offering nonsurgical approaches to pain and injury treatment), who suggested possible diagnoses, including cervical radiculopathy and carpal tunnel syndrome (CTS), to be confirmed by further testing. The physiatrist also recommended a nighttime wrist splint, a first line treatment for CTS—which  put an immediate stop to the nighttime attacks, after which C.W. learned that almost everything about CTS applied to her.

She had most of the risk factors—recent wrist fracture, arthritis, and being female: “women get carpal tunnel syndrome three times more often than men,” according to HopkinsMedicine. And she’s experienced most of the symptoms, starting with pain first noticed at night, described as “often a sharp burning stab or constant ache that seems to be coming from inside the hand and travel from the wrist up the arm.”

And she’d had most of the listed difficulties: discomfort when holding a phone; weakness in the hand, which results in dropping objects as well as in the thumb’s pinching muscles; and trouble fastening buttons or getting keys into locks.

CTS begins with narrowing of the carpal tunnel that results in pressure on the median nerve—which controls sensation in the palm and the palm sides of the thumb and first three fingers.  Created by bones and one thick ligament on top, the carpal tunnel also contains nine muscular tendons. According to StatPearls, “This high-traffic area is a prime spot for compression, and in fact, of all the entrapment neuropathies, carpal tunnel syndrome described below has been reported to be the most common.”

Women are more likely to experience CTS pain because the carpal tunnel is relatively smaller, or due to effects of hormones on the lining of carpal tunnel tendons, according to MayoClinic. Fluid retention can increase pressure and irritate the nerve inside the tunnel; anything that causes swelling in the wrist can put pressure on the median nerve; and narrowing of the tunnel can result from wrist fracture or dislocation as well as arthritis, which can change the small bones in the wrist.

C.W.’s doctor prescribed gabapentin, among nerve pain medications originally designed for treating depression or epilepsy. Gabapentin, an anticonvulsant that helps control seizures by decreasing abnormal excitement in the brain, can relieve neuropathic pain by changing the way the body senses pain, according to Medline Plus. For many people, carpal tunnel problems that significantly affect the median nerve can require surgery, in which the tendon is cut to relieve pressure on the nerve.

Meanwhile, among practical CTS remedies are keeping your hands warm; also, reducing your force, relaxing your grip and watching your form, according to the MayoClinic website. For force and grip, suggestions include pushing down more gently on computer keys as well as taking frequent short breaks and periodically stretching and bending hands and wrists.

And watching “form” means improving posture. For example, rolling shoulders back to avoid shortening neck and shoulder muscles—which can compress nerves in the neck. When using a computer keyboard, keep wrists parallel to the floor to avoid bending the wrist too far up or down. Also, use the keyboard at elbow height or slightly lower; and make sure that using a mouse doesn’t strain the wrist.

For C.W., after a years-long effort to work on posture, the midnight pain was a great motivator —albeit short-lived. After the splint started working, she made more resolutions and put up more self-reminders around her workspaces—trying to forestall backsliding with memories of that terrible midnight pain.

—Mary Carpenter regularly reports on topical subjects in health and medicine.