Nerve Pain · Postherpetic Neuralgia · Reviewed by Samuel Caruthers, MD
The rash cleared months ago. Everyone stopped asking about it. And you are still dealing with a band of burning across your ribs, or your face, or your back, that nobody can see and that does not seem to be going anywhere. A shirt seam is intolerable. Wind on the skin is intolerable. You are tired of explaining that yes, the shingles is over, and no, the pain is not.
This is postherpetic neuralgia, and it is the most common complication of shingles. It is also one of the most under-discussed, partly because the acute illness gets all the attention and the aftermath gets very little.
What happened to your nerve
Shingles is caused by reactivation of the varicella-zoster virus, the same virus responsible for chickenpox. After chickenpox resolves, the virus does not leave the body. It stays dormant in nerve cell clusters near the spinal cord and along certain cranial nerves, sometimes for decades.
When it reactivates, usually because immune surveillance has weakened with age, illness, or stress, it travels along a nerve to the skin. That is why the rash appears in a band on one side of the body, following the territory served by that single nerve.
The rash is the visible part. The damage happens along the nerve itself. Inflammation and viral activity injure nerve fibers, and injured nerves can continue firing abnormally long after the infection has resolved and the skin has healed.
Over time, a second process layers on top. Sustained abnormal input from a damaged nerve changes how the spinal cord and brain process signals from that region. Pathways become more responsive, so touch that should register as light pressure arrives as pain. This is central sensitization, the same amplification process that appears in other persistent pain conditions.
This is why the pain outlasts the infection. The virus is gone. The changes it produced in the nerve, and in how your nervous system handles signals from that nerve, are not.
Who develops it, and why age matters so much
Postherpetic neuralgia becomes markedly more likely with increasing age. It is uncommon in younger adults who get shingles and considerably more common in people over sixty, with risk continuing to rise from there.
Other factors associated with higher risk include severe pain during the acute shingles episode, an extensive rash, pain that began before the rash appeared, and involvement of the face or eye. None of these guarantees it, and plenty of people with none of them still develop it.
On prevention, because it is worth saying
The most effective step against postherpetic neuralgia is preventing shingles in the first place. The recombinant zoster vaccine is recommended for adults aged fifty and older, including those who have already had shingles, and it substantially reduces both the likelihood of an episode and the likelihood of lasting nerve pain afterward. If you have had shingles once, ask your primary care physician about it. This is not something we provide, and we mention it because it matters.
When shingles involves the face or eye
Shingles affecting the ophthalmic branch of the trigeminal nerve, which supplies the forehead, eyelid, and eye, deserves separate mention. It carries a higher risk of lasting nerve pain, and it can also threaten vision.
If you had shingles involving the face, particularly around the eye or the tip of the nose, and you have any ongoing visual symptoms, eye pain, or redness, that needs assessment by an ophthalmologist rather than a pain physician. Eye involvement is a different kind of problem from the nerve pain we treat, and it is time-sensitive.
Facial postherpetic neuralgia is also among the harder presentations to live with, because the affected area cannot be covered, protected, or avoided. Eating, shaving, washing, and wind all become sources of pain, and the constant visibility of the affected area makes it harder to put out of mind.
What it does to a day
Clinical descriptions of postherpetic neuralgia tend to focus on pain intensity, which misses most of what makes it difficult.
Sleep is usually the first casualty, because the affected area is disturbed by bedding and by turning over. Clothing becomes a daily calculation. Many patients quietly stop doing things, such as social plans, exercise, or hobbies involving the affected area, and the withdrawal happens gradually enough that nobody notices it as a change.
There is often a social dimension too. Because the rash has healed, the pain is invisible, and people who were sympathetic during the acute illness have moved on. Patients regularly describe feeling that they should be over it by now, which is not a medical fact but does affect whether they seek help.
All of this is worth mentioning at an appointment. Function, sleep, and what you have stopped doing tell a physician more about severity than a number on a scale.
What treatment usually starts with
First-line treatment for postherpetic neuralgia generally involves one or more of the following.
Gabapentin or pregabalin, which act on nerve signaling and are among the most commonly prescribed options. They help a meaningful proportion of patients, and sedation, dizziness, and cognitive dulling limit the dose many older patients can tolerate.
Tricyclic antidepressants such as amitriptyline or nortriptyline, used at doses lower than those used for depression. Effective for some, though anticholinergic side effects and cardiac considerations require caution in older patients.
Topical agents, including lidocaine patches applied over the affected area and high-concentration capsaicin patches applied in a clinical setting. These have the advantage of acting locally with limited systemic effect, which matters when someone is already on several medications.
A reasonable course of treatment works through these carefully, giving each an adequate trial. Many patients improve. Some do not, and it is that group this next section is for.
When first-line treatment is not enough
When the standard options have been tried at appropriate doses and the pain still prevents sleep and normal activity, several further approaches exist.
Nerve blocks and interventional procedures. Depending on the location, intercostal nerve blocks, paravertebral blocks, or sympathetic blocks may be considered, and these can be both diagnostic and therapeutic.
Neuromodulation. Spinal cord stimulation is used in some refractory cases, with a trial period before any permanent implant.
Ketamine infusion therapy. At low doses ketamine acts primarily as an NMDA receptor antagonist, and NMDA receptor activity is central to the amplification process described earlier. Because postherpetic neuralgia involves both peripheral nerve damage and central sensitization, targeting the central component is a mechanistically different strategy from anything in the first-line list.
An honest position on ketamine here
Ketamine is not FDA approved for postherpetic neuralgia and its use is off-label. The evidence in neuropathic pain generally is more encouraging than in some other pain categories, and it is still built on small studies with varying protocols and inconsistent reports of how long benefit lasts. Some patients respond well, some partially, and some not at all. Ketamine does not repair the damaged nerve.
A note on time
Postherpetic neuralgia does improve on its own for many people, gradually, over months and sometimes years. That is genuinely good news and it is also cold comfort if you are two years in and nothing has changed.
The reason to seek treatment rather than simply wait is twofold. Pain severe enough to disrupt sleep and activity causes real harm while you wait, including deconditioning, isolation, and low mood. And there is reason to think that pain which has been established and amplified for a long time becomes harder to reverse, which argues against indefinite patience.
| Option | How it works | Practical notes |
|---|---|---|
| Gabapentin / pregabalin | Modulates nerve signaling | First line, daily, sedation often limits dose in older patients |
| Tricyclics | Descending pain inhibition | Low doses, requires caution with cardiac and cognitive side effects |
| Topical lidocaine or capsaicin | Local action at the skin and nerve endings | Minimal systemic effect, useful alongside other treatments |
| Nerve blocks | Interrupting signaling at a specific nerve | Diagnostic and therapeutic, duration varies |
| Ketamine infusion | NMDA receptors, central amplification | Off-label, self-pay, requires a driver, typically a series |
What an evaluation involves
We will want to know when the shingles episode occurred, where it was, how severe the acute pain was, what the pain is like now, and what has been tried with what result. An examination checks the affected area for sensory changes, including whether light touch produces pain.
From there the conversation is about which options are appropriate, in what order, and what would be realistic. Because this population is often older and frequently taking several medications, a careful review of your full medication list and medical history is part of the process rather than a formality.
Our Parsippany office serves Morris County including Towaco and Mount Tabor, with additional locations in Clifton, Hackettstown, and Hamburg. No referral is needed.
Bringing the right information to your visit
A few specifics make a first appointment considerably more useful. When the shingles episode occurred, even approximately. Where the rash was. Whether antiviral medication was started, and how quickly after the rash appeared. How severe the acute pain was compared with now. And a list of everything tried since, with doses and what happened on each.
It is also worth noting what you can no longer do, since function is often a better measure of severity than a pain score and it gives us something concrete to aim at.
Frequently asked questions
How long does postherpetic neuralgia last?
It varies enormously. Many people improve gradually over months to a few years. A minority have pain that persists indefinitely without treatment. Older age and more severe acute pain are associated with longer duration.
Am I still contagious?
No. Once the rash has crusted over and healed, you are not contagious. Postherpetic neuralgia is nerve pain left behind, not ongoing infection.
Can I get shingles again?
Yes, recurrence is possible, which is one reason vaccination is recommended even for people who have already had an episode. Ask your primary care physician.
Why does my shirt hurt?
That is allodynia, where a stimulus that should not be painful is experienced as painful. It reflects the sensitization of the nerve and the pathways carrying its signal, and it is a characteristic feature rather than an exaggeration.
Is it too late to treat if it has been years?
Not necessarily. Longstanding pain can be harder to change, but it is still worth an assessment. We will tell you honestly what we think is achievable rather than starting treatment without a realistic expectation.
Will insurance cover this?
This is an out-of-network practice that does not participate with Medicare or Medicaid, and ketamine infusion for chronic pain is generally not covered. Costs are discussed clearly before any treatment.
The shingles is over. The pain does not have to be permanent.
A consultation will review what has been tried, what has not, and whether anything further is likely to help in your case.
Medical disclaimer. This article is for general educational purposes and is not medical advice, nor does it create a physician-patient relationship. Ketamine infusion therapy for postherpetic neuralgia is an off-label use and is not FDA approved for this indication. Individual results vary and no outcome is guaranteed. Vaccination decisions should be discussed with your primary care physician. Do not start, stop, or change any medication based on this article. If you are experiencing a medical emergency, or if shingles affects your eye, seek medical care immediately.