Medications are usually the first course of action. The apparent neuropathic nature of PLP would suggest that antidepressants, anticonvulsants, and other medications used for neuropathic pain would be most efficacious. However, Ephraim and coworkers4 found that most patients are treated with acetaminophen, NSAIDs, and opioids.
As with any neuropathic pain, the antidepressants that affect both the serotonergic and noradrenergic systems appear to provide the strongest analgesic effects. In a recent randomized, placebo-controlled study, Wilder-Smith and colleagues7 reported that 25 of 30 patients with PLP responded to treatment with amitriptyline(Drug information on amitriptyline) (Elavil), and 22 of 33 patients responded to tramadol(Drug information on tramadol) (Ultram) (a drug that is a mixture of a serotonin/norepinephrine reuptake inhibitor and a weak opioid), compared with only 2 of 37 patients who responded to placebo. If tricyclic antidepressants cannot be tolerated or their use is contraindicated, venlafaxine (Effexor) or duloxetine(Drug information on duloxetine) (Cymbalta) (both of which, like the tricyclics, are serotonin/norepinephrine reuptake inhibitors) should be considered as an alternative. However, I am unaware of any published studies on their use for the treatment of PLP.
There are studies indicating that at least 2 anticonvulsants, gabapentin(Drug information on gabapentin) (Neurontin) and topiramate(Drug information on topiramate) (Topamax), may be beneficial for PLP.8,9
Another medication for neuropathic pain that I have found useful at times for the treatment of PLP is the lidocaine(Drug information on lidocaine) patch (Lidoderm). This medication has the advantage of being without significant side effects and, therefore, can be used safely even in patients with severe medical problems.
Psychologically based modalities may also provide relief. Therapies such as biofeedback and hypnosis may directly affect the physiologic processes involved in the pain. Other therapies that may be beneficial include peripheral nerve blocks, epidural infusion of analgesic agents, transcutaneous electrical nerve stimulation, and acupuncture. Surgical interventions—including sympathectomy, rhizotomy, cordotomy, and most recently, deep brain stimulation—have also been used.10