When should I consider referring a patient with neuropathic pain to a specialist?

Consider referring a patient with neuropathic pain to a specialist pain service or neurologist if:

• They have severe pain that is not adequately controlled despite treatment in primary care.
• The pain significantly limits their participation in daily activities, including self-care, general tasks, interpersonal relationships, mobility, and sleep.
• Treatment options available in primary care have been exhausted but symptoms remain significant.
• The patient experiences poorly tolerated side effects from neuropathic pain medications despite attempts at slower titration or switching drugs.
• Combination therapy is needed because pain remains uncontrolled on a single neuropathic pain drug.
• Psychological therapies such as cognitive behavioural therapy are considered, or if psychological impact is significant.
• At any stage, including initial presentation or during regular clinical reviews, if pain is severe, significantly impacts quality of life, or the underlying condition deteriorates.

Specialist treatments may include stronger capsaicin patches, nerve blocks, injections or stimulation, Botulinum Toxin A injections, transcutaneous electrical nerve stimulation (TENS), and other psychological interventions.

For trigeminal neuralgia specifically, referral should be considered early if initial treatment with carbamazepine is ineffective, not tolerated, or contraindicated, or if the diagnosis is uncertain or surgery is being considered.

Regular clinical reviews should assess pain control, impact on lifestyle, physical and psychological wellbeing, and adverse effects to guide referral decisions.