Medications for postherpetic neuralgia

First-line Treatments:
1. Tricyclic Antidepressants
Most efficacious medications for PHN
Nortriptyline preferred over amitriptyline (better tolerated, equal efficacy)
Limited by anticholinergic side effects, especially in elderly

2. Anticonvulsants
Gabapentin and pregabalin
Well-tolerated, few side effects; Non-addictive

3. Opioids: Tramadol (combined opioid and SNRI) is a first-line option

Topical: Lidocaine (specifically for allodynia)

Interventional Options (for refractory cases):
Epidural/intrathecal methylprednisolone with local anesthetic
Spinal cord stimulation
Alcohol neurolysis

Not Effective:
NSAIDs (like ketorolac)
Antivirals (like acyclovir) - not beneficial for established PHN

Treatment Approach:
These medications can be used in combination due to synergistic effects
Should be tailored to individual patient tolerance, especially in elderly
Over 90% of PHN patients experience allodynia, which influences treatment choices