Face pain

A guide for patients and carers

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Post-herpetic neuralgia

Post-herpetic neuralgia is a form of chronic facial pain that follows an attack of shingles (herpes zoster) on the face.

What is shingles?
Shingles is caused by the chicken pox virus, which most people get as a child. Shingles, however, usually occurs in older people. What happens is that the virus, which has been lurking in the body for many years, suddenly attacks a single nerve. It most commonly affects a nerve in the skin of the upper body, but it may attack the nerves in the head and face. It only affects one side of the face.

The illness follows a pattern. It begins with a dull pain in the facial skin. This is followed within a few days by the eruption of a weeping rash, which usually clears up within a few weeks or perhaps less with the help of certain drugs such as acyclovir. Some people are unfortunately left with scarring, but the vast majority of people find that the pain settles down and the rash goes away without leaving a scar.

How does this lead to post-herpetic neuralgia?
In rare cases, especially in people over 65 years of age, the pain continues for over a month after the shingles has gone and it is this chronic pain which is called post-herpetic neuralgia (herpes zoster is the medical name for shingles). The pain is usually of a burning, aching or throbbing nature and may often be accompanied by extreme tenderness. The wind blowing against the face or clothes rubbing it may be unbearable to sufferers, although firm pressure may not cause a problem. Despite the extreme tenderness in the affected area, the skin’s general sensitivity may actually be reduced.

As with many chronic pains the symptoms may be worsened by physical or mental stress. In addition, sleep is often interrupted as bedclothes brush against the face.

What causes the pain?
The chicken pox virus damages the nerve and as a result the area supplied by that nerve goes partly numb. However, the damaged nerve pathways then start to generate pain. Precisely how this comes about is unknown.

Who gets post-herpetic neuralgia?
Anyone who has had shingles may get post-herpetic neuralgia, although it is very rare for young adults to develop it. Around 100,000 people per year in the UK develop post-herpetic neuralgia on some part of the body and only a small percentage of these will have it in the face.

What treatment is available?
If after an attack of shingles on the face you still have pain a month after the rash has settled down you should go to see your doctor immediately as the effects of treatment are much better when given early. Ordinary painkillers usually have little effect and so may waste valuable time.

The main drug used for this condition is amitriptyline. This drug is more commonly used for depression, but it has a very powerful effect on certain forms of nerve pain. You may need to take it for two or three weeks before it provides relief.

Other medicines which may also be prescribed include creams and lotions which act as a local anaesthetic and numb the area to which they are applied, and the anticonvulsant drug carbamazepine (Tegretol), which is taken by mouth. Gabapentin (Neurontin) has been found to be effective and has fewer side effects than carbamazepine.

Surgical procedures to cut the nerve, such as those used in the treatment of trigeminal neuralgia, are always ineffective.

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