Nerve pain, explained
Neuropathic pain: what it feels like and what relieves it
Neuropathic pain comes from the nerves themselves, not from an injured joint or muscle. It burns, shoots or buzzes, it is often worse at night, and it responds to a different set of treatments from ordinary pain.
Written by the Managing Neuropathy editorial team under the direction of Dr. Tom Biernacki, DPM, FACFAS · Clinical review pending · Last updated 24 September 2026
The short answer. Neuropathic pain is pain caused by damage or disease in the nerves that carry sensation. It feels different from the ache of a sprain: burning, electric shocks, stabbing or pins and needles, often in an area that is also numb, and light touch can hurt. Somewhere between 7 and 10 in every 100 adults have pain with these features, and in the feet the most common cause is diabetes. There’s little evidence that ordinary painkillers help. Most guidelines start with one of three families of medicine, add skin treatments for pain in one area, and keep opioids for last. Finding and treating the cause matters as much as treating the pain.
What neuropathic pain feels like
The International Association for the Study of Pain defines neuropathic pain as pain caused by a lesion or disease of the somatosensory nervous system: the nerves that carry touch, temperature and pain signals. In plain terms, the wiring is damaged, so it sends pain signals it shouldn’t.
People describe it in a recognizable way: burning, shooting, stabbing or like an electric shock, often with pins and needles. Two features set it apart from other pain:
- Pain and numbness in the same place. The skin can feel dull or “dead” to touch and still burn. That combination is one of the strongest clues that a nerve is involved.
- Things that shouldn’t hurt, hurt. Bedsheets, socks or a light brush against the skin can be painful. Doctors call this allodynia.
Timing is a clue too. A 2022 review of the research on daily rhythm found that neuropathic pain tends to build through the day and peak in the late evening and early night, roughly the opposite of inflammatory joint pain such as rheumatoid arthritis, which is often worst in the morning. This may be one reason so many people with burning feet notice it most when they lie down.
Where it hurts narrows the cause. Neuropathy from diabetes and most other body-wide causes starts in the toes of both feet and creeps upward. Pain in one foot, along one strip of the leg, or around the inside of the ankle points more toward a single nerve being squeezed. Our guide to nerve pain in the foot maps the common patterns.
Neuropathic pain vs. ordinary (nociceptive) pain
Most everyday pain is nociceptive: healthy nerves correctly reporting damage or inflammation in tissue, such as a sprained ankle, arthritis or plantar fasciitis. Neuropathic pain is the nerve itself misfiring. The difference matters because the treatments are different.
| Nociceptive pain | Neuropathic pain | |
|---|---|---|
| Where it comes from | Injured or inflamed tissue: a joint, tendon, muscle or bone | A damaged or diseased nerve |
| How it feels | Aching, throbbing, sore | Burning, electric, stabbing, pins and needles |
| Numbness nearby | Unusual | Common |
| Light touch | Feels normal | Can hurt (allodynia) |
| Typical timing | Worse with use; inflammatory arthritis is often worst in the morning | Often builds through the day and peaks at night |
| What tends to help | Rest, ice, anti-inflammatories, treating the injury | Nerve-pain medicines, skin treatments, treating the cause |
The two often overlap. Sciatica can combine an irritated nerve root with back pain from the joints, and someone with neuropathy can also have arthritis in the same foot. A third category, nociplastic pain, describes a nervous system that has become oversensitive without clear nerve damage; fibromyalgia is the usual example.
What causes it
The international classification of chronic pain used in ICD-11 sorts neuropathic pain by where the damage sits.
Damage to nerves outside the brain and spinal cord
- Painful polyneuropathy. Many nerves affected at once, usually starting in the feet. Diabetes is the most common cause; others include heavy alcohol use, some chemotherapy drugs, low vitamin B12 and inherited neuropathies. See diabetic neuropathy and alcohol-related neuropathy.
- A trapped or irritated nerve. A nerve root pinched in the spine (radiculopathy, which includes sciatica) or a nerve compressed along its path, as in tarsal tunnel syndrome. Radiculopathy vs. neuropathy explains how to tell them apart.
- Nerve injury. After surgery, a fracture or a crush injury. Nerve pain after foot or bunion surgery belongs here.
- After shingles. Postherpetic neuralgia is pain that outlasts the shingles rash, in the same band of skin.
- Trigeminal neuralgia. Brief, severe, electric-shock pain in the face. It is treated differently from the rest.
Damage inside the brain or spinal cord
Central neuropathic pain can follow a stroke or a spinal cord or brain injury, or occur with multiple sclerosis. It is less common, and neurologists and pain specialists usually manage it.
How it’s diagnosed
Neuropathic pain is diagnosed mainly by listening and examining. A clinician looks for two things: pain in an area that fits a particular nerve or nerve pattern, and changed sensation in that same area when it is tested with light touch, a pin, vibration or temperature.
Short questionnaires help. One widely used questionnaire, the DN4, has seven questions about how the pain feels and three quick examination checks; a score of 4 or more out of 10 suggests the pain is neuropathic. Others include painDETECT and LANSS. They support the examination rather than replace it.
Then comes the search for the cause, which is often where treatment starts:
- Blood tests, including glucose or HbA1c, vitamin B12, and thyroid and kidney function, with others depending on the story.
- Nerve conduction studies and EMG for the larger nerve fibers. A normal result doesn’t rule out small fiber neuropathy, which is confirmed with a small skin biopsy instead.
- An MRI when a pinched nerve root in the spine, or a cause in the brain or spinal cord, is suspected.
Treatment: what the guidelines recommend
There’s little evidence that acetaminophen or anti-inflammatory painkillers such as ibuprofen help nerve pain, and the major guidelines don’t list them as treatments for it. The evidence points to a specific ladder instead. The neuropathic pain group of the International Association for the Study of Pain (NeuPSIG) updated it in 2025, and NICE in the UK and the American Academy of Neurology (for diabetic nerve pain) start with the same families of medicine, with some differences in detail.
Low-dose tricyclic antidepressants (amitriptyline, nortriptyline), SNRIs (duloxetine, venlafaxine) and the gabapentinoids (gabapentin, pregabalin). All three carry a strong recommendation. They are used for their effect on nerve signaling, so you don’t need to be depressed or have seizures for them to make sense.
A high-strength capsaicin 8% patch applied in the clinic, lidocaine 5% patches and capsaicin cream. In the United States, the capsaicin 8% patch (Qutenza) was approved in 2020 for painful diabetic neuropathy of the feet.
Botulinum toxin is injected into the painful skin; rTMS is a noninvasive magnetic stimulation of the brain. Opioids come last because of their risks, and the American Academy of Neurology recommends against them for painful diabetic neuropathy.
A high-frequency (10 kHz) stimulator was approved by the FDA for painful diabetic neuropathy in 2021. In the trial behind it, which was not blinded, 85% of people with the stimulator had at least half their pain relieved at six months, compared with 5% on usual care. It is an implanted device with surgical risks, so it is a later step.
Two practical points make the difference between giving up and getting relief. The first is expectations: the NeuPSIG authors describe the results of even the best treatments as modest, so a good outcome usually means the pain is turned down, not switched off. The second is persistence: NICE advises that if the first medicine doesn’t work or isn’t tolerated, the next step is one of the others, and then another. Doses usually start low and rise gradually, which is why a fair trial takes weeks.
Each family has its own side effects and interactions, so the right first choice depends on your other conditions, medicines, sleep and mood. One safety point is worth knowing: in 2019 the FDA warned that gabapentin and pregabalin can cause serious breathing problems in people who also take opioids or other sedating drugs, in people with lung disease such as COPD, and in older adults. Our page on peripheral neuropathy medication goes through each option.
Trigeminal neuralgia is the exception to the ladder: NICE recommends carbamazepine as its first treatment.
Treating the cause, and what helps at home
Medicines treat the signal. The cause is where the longer-term gains are:
- Diabetes. Steadier blood glucose, blood pressure and cholesterol can slow further nerve damage, though they usually can’t restore fibers that are already lost.
- Correctable causes. Low vitamin B12, heavy drinking, a medicine or a squeezed nerve can each improve once dealt with, sometimes more than people expect.
- The feet themselves. Numb, painful feet get hurt without noticing. A daily look, well-fitting shoes and prompt care of any wound protect them.
Day to day, staying active helps sleep, mood and circulation, and our guide to neuropathy exercises covers what is safe when the feet are numb. For burning feet at night, these steps help many people sleep. Creams and patches you can buy are compared in neuropathy creams, and the supplements with the most evidence are in supplements for neuropathy.
When to get checked quickly
Most nerve pain builds slowly. These patterns need a same-day call or an emergency visit:
- Numbness or weakness that climbs up both legs over hours or days.
- Loss of bladder or bowel control, or numbness around the groin and buttocks, together with back pain.
- New weakness, such as a foot that drops or slaps when you walk.
- A painful rash in a band on one side of the body, which can be shingles. Antiviral treatment works best when it is started early.
- With diabetes: a wound, redness, swelling or a color change in a numb or painful foot.
Common questions
Is neuropathic pain the same as neuropathy?
Not quite. Neuropathy means nerve damage, and many people with neuropathy have numbness or tingling without much pain. Neuropathic pain is pain produced by damaged nerves. Painful diabetic neuropathy is its most common form in the feet.
What is the best medication for neuropathic pain?
There isn’t a single best one. Most guidelines put three families first: low-dose tricyclic antidepressants such as amitriptyline, SNRIs such as duloxetine, and gabapentin or pregabalin. The choice depends on your other conditions and medicines, and if the first doesn’t help, another is usually tried.
Can neuropathic pain go away?
Sometimes. It can ease when a squeezed nerve is released, a vitamin deficiency is corrected or heavy drinking stops, and pain after shingles often fades over months, though not always. Long-standing diabetic nerve pain usually needs ongoing treatment, and it can often be reduced.
Why is nerve pain worse at night?
Research on daily rhythm shows neuropathic pain tends to rise through the day and peak late in the evening. Fewer distractions, bedsheets touching sensitive skin and changes in skin temperature may add to it. Treating the pain, and the steps in our guide to burning feet at night, often help.
Do regular painkillers help nerve pain?
Not much. Acetaminophen and anti-inflammatories such as ibuprofen aren’t among the recommended treatments for neuropathic pain, though they can help with joint or muscle pain that sits alongside it.
Related reading
Diabetic neuropathy · Nerve pain in the foot · Peripheral neuropathy medication · Burning feet at night · Small fiber neuropathy · Benfotiamine for neuropathy
Sources and further reading: International Association for the Study of Pain, identifying neuropathic pain in the clinic (definition, descriptors, allodynia, screening questionnaires). Soliman N et al., pharmacotherapy and non-invasive neuromodulation for neuropathic pain (the 2025 NeuPSIG review and recommendations), Lancet Neurol 2025;24:413–428. NICE, neuropathic pain in adults: pharmacological management in non-specialist settings (CG173). Price R et al., oral and topical treatment of painful diabetic polyneuropathy, American Academy of Neurology guideline, Neurology 2022;98:31–43. van Hecke O et al., neuropathic pain in the general population, Pain 2014;155:654–662. Scholz J et al., the IASP classification of chronic pain for ICD-11: chronic neuropathic pain, Pain 2019;160:53–59. Bouhassira D et al., development of the DN4 questionnaire, Pain 2005;114:29–36. Hu S et al., diurnal variation in the intensity of neuropathic pain, Pain Med 2022;23:991–1005. FDA warning on breathing problems with gabapentin and pregabalin (December 2019). Qutenza (capsaicin 8%) prescribing information, 2020. Nevro, FDA approval of 10 kHz spinal cord stimulation for painful diabetic neuropathy (July 2021). Petersen EA et al., 10-kHz spinal cord stimulation for painful diabetic neuropathy, JAMA Neurol 2021;78:687–698.
For our Michigan neighbors
Nerve pain keeping
you up at night?
The first step is finding out which nerves are involved and why. An examination and the right tests usually get there. Dr. Biernacki’s Michigan practice can start there.
Everywhere else, take this page to your own clinician.
Dr. Tom Biernacki, DPM, FACFAS is a double board-certified foot and ankle surgeon (ABFAS and ABPM) and a Fellow of the American College of Foot & Ankle Surgeons. He is the founder of Balance Foot & Ankle in Howell and Bloomfield Township, Michigan, where peripheral neuropathy, diabetic foot risk and loss of protective sensation are part of his weekly clinic. His patient education videos have drawn more than 950,000 subscribers on YouTube. Managing Neuropathy is written by its editorial team under his direction, to put the explanation he gives in the exam room in front of the people who cannot get to one — including when a product is worth buying and when it is not.