Shingles Pain Won't Stop? It's Postherpetic Neuralgia, Not a Failed Recovery

Postherpetic neuralgia is the burning, shooting nerve pain that continues after shingles — and for many patients, first-line medications don't bring enough relief. This episode explains why, & what targeted treatment options exist. In this episode of The Pain Diaries, Dr Nick Christelis (FFPMANZCA) sits down with Dr Roshan Thawale (FFPMANZCA) , both Specialist Pain Medicine Physicians at Pain Specialists Australia, for an honest conversation about postherpetic neuralgia — why it persists, why medication often isn't enough, & what targeted options exist. Full PHN guide: https://painspecialistsaustralia.com.... WHAT IS POSTHERPETIC NEURALGIA (PHN)? PHN is persistent nerve pain that continues for three months or more after shingles. It affects 5 to 15% of people who have shingles, rising sharply in adults over 60. PHN is not ongoing infection — it's nerve injury and sensitisation caused by the varicella-zoster virus damaging the dorsal root ganglion. WHY DON'T GABAPENTIN AND PREGABALIN ALWAYS WORK? They reduce nerve excitability across the whole nervous system, but PHN is often a localised problem driven by one damaged dorsal root ganglion. A systemic medication may not achieve enough modulation at the site of injury without doses that cause sedation, cognitive dulling, or balance problems. WHAT DOES PHN FEEL LIKE? Patients describe burning, shooting, stabbing pain, often worse at night. The most distressing feature is allodynia (when light touch, clothing, or a breeze causes intense pain). Some describe it as molten lava poured on the skin. This is real biological nerve sensitisation, not a psychological response. WHEN SHOULD YOU SEE A PAIN SPECIALIST? If you've trialled gabapentin, pregabalin, amitriptyline, or another first-line medication for 4 to 6 weeks without adequate relief, it's time for specialist assessment. The longer PHN persists, the more central sensitisation establishes, making treatment more complex. WHAT TREATMENT OPTIONS EXIST BEYOND MEDICATION? The full treatment ladder: topical agents (lidocaine 5% plasters, capsaicin), compounded creams, other oral medications (duloxetine, nortriptyline), nerve blocks, pulsed radiofrequency of the dorsal root ganglion, stellate ganglion block for facial PHN, & ketamine infusions for selected patients. DOES THE SHINGLES VACCINE REDUCE PHN RISK? Yes. Shingrix offers approximately 65 to 75 per cent protection against severe PHN. It's recommended for adults over 65, Aboriginal & Torres Strait Islander adults over 50, & immunocompromised adults of any age. A 2025 Nature study also suggests Shingrix may be associated with reduced dementia risk. TIMESTAMPS 00:00 The molten lava: what PHN actually feels like 00:50 Welcome & what this episode covers 02:39 Why PHN persists after the rash resolves 06:38 Who is most at risk: age, immunosuppression, and stress 06:52 Why gabapentin, pregabalin & amitriptyline often fail 10:48 When to see a pain specialist (the 2-3 month rule) 12:07 What specialist pain assessment actually involves 12:35 Why mental health matters in PHN management 14:05 Topical lidocaine, capsaicin & compounded creams 16:01 Nerve blocks and pulsed radiofrequency of the DRG 18:40 "Are you gonna burn my nerves?" - PRF safety explained 20:32 Stellate ganglion block, intercostal and paravertebral blocks 24:24 Shingrix: the shingles vaccine and PHN prevention 24:59 The 2025 Nature study: shingles vaccine and dementia 28:33 Ketamine infusions for PHN: who should have it & who should not 31:52 Final message to anyone living with PHN WATCH NEXT Solo episode on PHN with Dr Nick Christelis:    • Shingles Pain That Won't Stop: The Targete...   THE NEXT PODCAST A deep dive into ketamine infusions for chronic pain - how they work, who they help, and how they differ from ketamine for depression. ABOUT THE HOSTS Dr Nick Christelis is a Specialist Pain Medicine Physician (FFPMANZCA) and founder of Pain Specialists Australia, a multidisciplinary private chronic pain team across Richmond, Heidelberg, & Sandringham (Bayside), Melbourne. Dr Roshan Thawale is a Specialist Pain Medicine Physician (FFPMANZCA) at Pain Specialists Australia with extensive experience in interventional pain management & neuropathic pain. painspecialistsaustralia.com.au DISCLAIMER This video is for general education only. It's not medical advice and does not establish a doctor-patient relationship. Some treatments discussed (including compounded creams & ketamine infusions) are off-label and only suitable for selected patients following specialist assessment. All interventional procedures carry risks discussed in clinical consultation. Patient experiences described are illustrative, not guaranteed outcomes. Vaccine decisions should be made with your GP. Emerging research findings require further study. Always consult your treating clinician before changing your treatment plan. Full PHN information: https://painspecialistsaustralia.com....