Pain management

(Agent report, 2026-09-03. Reviewed by Kya at synthesis.)

Guidelines (verbatim)

• NICE CG173: 1.1.8 "Offer a choice of amitriptyline, duloxetine, gabapentin or pregabalin as initial treatment for neuropathic pain (except trigeminal neuralgia)." 1.1.13 "Offer carbamazepine as initial treatment for trigeminal neuralgia." 1.1.12 morphine/oxcarbazepine not to be started for neuropathic pain in non-specialist settings unless specialist advises. 1.1.2 refer to specialist pain service at any stage if severe pain.
• NICE CG140 (opioids in palliative care): 1.1.4 regular oral morphine "with rescue doses… for breakthrough pain"; 1.1.5 typical start 20-30 mg/day oral morphine; 1.1.6 frequent review in titration; 1.1.18 laxative for all; 1.1.1 address "fears that treatment implies the final stages of life".
• ESMO 2018 (Fallon): "Analgesics for chronic pain should be prescribed on a regular basis and not on an 'as required' schedule [V, D]"; ATC administration [II, B]; TCA or anticonvulsant for NP [I, A]; "Other adjuvants such as steroids should be considered in the case of nerve compression"; ketamine lack of evidence [II, D]; ~10% need interventional techniques.
• WHO 2018: "By the clock… The next dose should be given before the effect of the previous dose has worn off." Regular morphine + rescue (strong rec). Steroids when indicated, shortest period.
• FPM Core Standards 2021: 3.6.6 complex inpatient pain assessed by IPS "within 24 hours"; 6.6.7 cancer pain "must be referred for more specialist advice… if pain is not improving within a short time"; 1 in 3 cancer pain undertreated.
• Scottish Palliative Care Guidelines: IR morphine 5mg 4-hourly + PRN when titrating; increase ~30%/day; neuropathic — "specialist advice should be sought early"; amitriptyline 10mg nocte, gabapentin from 300mg/day (lower if on opioids), pregabalin 25mg bd; dexamethasone 4-8mg/day for nerve pain 3-5 days then minimum.
• RCS FDS Trigeminal Neuralgia 2021: "There is no evidence supporting the role of opiates/opioids in the management of TN." Carbamazepine NNT 2, 800-1200 mg/day; oxcarbazepine alternative; anticonvulsants take days → bridge with intranasal lidocaine 10mg/spray x2 (strong rec) / topical 5% lidocaine. Red flags: malignancy, age <30.
• NICE CG138 1.2.8: "do not assume that pain relief is adequate; ask them regularly about pain; assess pain using a pain scale".

Steroids/lymphoma

• StatPearls CNS lymphoma: withhold steroids pre-biopsy; inconclusive 3x more likely; "vanishing tumors" up to 50%. Scheichel 2021 pooled OR 3.3. Cochrane Haywood 2015: steroid pain benefit weak, short-lived. Ryken 2010: dex 4-8 mg/day for ICP symptoms.
• Inference: chordoma is extradural/bony; less oedema rationale for dex than intra-axial tumour.

Interventional

• SPG block: pain reduced 38-80%, mean ~23 days (2019 series); H&N cancer series VAS 8.6->2.5. Best for V2.
• Gasserian procedures: MDT/skull-base decision with tumour in CS.
• IV lidocaine: Lee 2019 meta-analysis 4-5 mg/kg over 30-80 min benefit in refractory cancer pain. Ketamine: Cochrane insufficient evidence.

NNTs (Finnerup 2015 Lancet Neurol): TCA 3.6; SNRI 6.4; pregabalin 7.7; gabapentin 6.3; strong opioids 4.3 (NNH 11.7) — third line. Cochrane morphine NP: very low quality, no difference for substantial relief. Oxycodone NNT 5.7 / NNH 4.3.

Practical asks

1 regular background analgesia not PRN-only; 2 regular paracetamol ± NSAID (bleeding caveat pre-biopsy); 3 neuropathic adjuvant now; 4 carbamazepine/oxcarbazepine if paroxysmal/trigger pain; 5 intranasal/topical lidocaine bridge; 6 acute pain team (24h standard); 7 palliative/supportive care team ("symptom control not end of life"); 8 documented pain scores; 9 laxative + antiemetic; 10 steroids: ask, don't demand — expedite biopsy instead; 11 escalate 24h: nurse in charge → registrar/consultant → PALS. Caveats: BSH 2019 and NHSE ESC full texts not fetched.