Understanding the Difference to Improve Diagnosis and Outcomes
When a patient presents with chronic pain, the first step to effective management is identifying what kind of pain they’re experiencing. Is it nociceptive—arising from tissue damage and inflammation? Or is it neuropathic—caused by nerve dysfunction or injury?
Distinguishing between these types is critical, as neuropathic pain typically doesn’t respond well to conventional analgesics like NSAIDs or opioids. For GPs and allied health professionals, being able to spot the red flags of neuropathic pain can ensure earlier referrals, better treatment pathways, and improved patient outcomes.
Below, we explore the top five clinical signs that indicate a patient’s pain may be neuropathic—not nociceptive.
1. Burning, Shooting, or Electric Shock-Like Sensations
Neuropathic pain often feels unnatural. Instead of a dull ache or throbbing, patients may describe:
- A “burning” or “freezing” pain
- Sudden jolts like an electric shock
- Stabbing, shooting discomfort that follows a nerve path\
These descriptors are rarely used in nociceptive pain, making them strong diagnostic clues.
Tip for GPs: Ask open-ended questions like “How would you describe the pain in your own words?” Patients will often volunteer neuropathic descriptors when prompted this way.
2. Pain Disproportionate to the Stimulus (Allodynia)
One of the hallmark signs of neuropathic pain is allodynia—when a normally non-painful stimulus causes pain. Examples include:
- Pain from light touch (e.g. clothing brushing the skin)
- Pain from gentle pressure
- Discomfort from mild temperature changes
This hypersensitivity can be highly distressing for patients and is not typically present in nociceptive conditions.
Clinical Note: Allodynia is especially common in conditions like postherpetic neuralgia, complex regional pain syndrome (CRPS), and diabetic neuropathy.
3. Tingling, Numbness, or Pins and Needles (Paresthesia)
Neuropathic pain often comes with sensory abnormalities like:
- Tingling
- Numbness
- “Pins and needles” sensations
These symptoms reflect damage or dysfunction in the sensory pathways. While paresthesia can sometimes accompany nociceptive issues (e.g., radicular pain from disc herniation), its persistence and prominence are more suggestive of a neuropathic origin.
GP Action Point: If paresthesia persists after tissue healing, it’s time to consider neuropathic causes and specialist referral.
4. Poor or Absent Response to Conventional Pain Medications
Neuropathic pain is notoriously stubborn when treated with standard pain relief options.
- NSAIDs often have little effect
- Opioids may offer only partial relief
- Corticosteroids typically fail to address the underlying issue
If a patient’s pain remains high despite appropriate treatment for presumed nociceptive pain, this is a strong cue to reassess the pain mechanism.
Next Step: Consider medications like gabapentinoids, SNRIs, or tricyclic antidepressants—used more effectively in neuropathic pain pathways.
5. History of Nerve Injury or Underlying Neurological Condition
Neuropathic pain often has a traceable origin, such as:
- Trauma or surgery that affected nerve tissue
- Stroke or multiple sclerosis
- Diabetic neuropathy
- Chemotherapy-induced peripheral neuropathy
- Herpes zoster (leading to postherpetic neuralgia)
Always dig into a patient’s medical history. Neuropathic pain can emerge weeks—or even months—after the initial nerve insult.
Ask Yourself: “Could this patient have had a nerve insult—even subclinical—that might explain the current symptoms?”
Why This Matters for You and Your Patients
Identifying neuropathic pain early leads to:
- Timely referrals to pain specialists or neurologists
- More targeted pharmaceutical management
- Reduced patient distress and diagnostic delays
- Better long-term functional outcomes
Refer When in Doubt
Chronic neuropathic pain rarely resolves on its own—and mismanagement can lead to patient frustration, disability, and even mental health decline. If you suspect neuropathic pain, or if conventional management isn’t effective, it’s time to refer.
At Axxon Pain Medicine we offer multidisciplinary assessments and evidence-based interventions tailored to neuropathic pain patients. We’re here to support your practice with specialist insights and collaborative care.
Know the Common Conditions That Hide Neuropathic Pain
- Diabetes: Often masked by musculoskeletal complaints
- Shingles survivors: Pain can persist as postherpetic neuralgia
- Carpal tunnel syndrome: Not always just about numb hands
- Post-surgical scars: Can produce chronic nerve pain
- Cancer treatments: Chemotherapy or radiation may cause nerve damage
The line between nociceptive and neuropathic pain isn’t always black and white—but knowing the signs can help you make faster, more confident decisions.
For patients who aren’t improving on standard care, it may be time to explore a deeper cause—one that starts not in the tissue, but in the nerves.
