Maged El-Ansary Th e maximum dose is 150 mg q.i.d., but most patients will do ne with 50100 mg q.i.d. If slow-release formulations are available, the daily dose has to be divided (b.i.d. to t.i.d.). Th e typical side e ects of nausea and vomiting should be less frequent with the slow-release formulation. Alternatives to tramadol are codeine and dextropropoxyphene. If I have coanalgesics available, how do I choose the right one for my patient with acute herpes zoster?

Generally speaking, for herpes zoster, coanalgesics should be chosen according to the guidelines published on neuropathic pain, since acute herpes zoster causes mostly neuropathic pain. Th erefore, the drug of rst choice would be either amitriptyline or gabapentin (or a comparable alternative such as nortriptyline or pregabalin). Th e decision between a tricyclic antidepressant and an anticonvulsant should be made according to the typical side-e ect pro le. Patients with liver diseases, reduced general condition, heart arrhythmias, constipation, or glaucoma should receive gabapentin or pregabalin. Th ese are presumably weaker analgesics, but they have the great advantage that no serious side effects are to be expected. Also, no ECG or blood tests have to be performed. Both drug families have their best e cacy against constant burning pain, but they may be insu cient for attacks of shooting or electrical pain. For other drug options, refer to the appropriate chapters in this ma

I have tried local and systemic therapeutic options, but the patient still has excruciating pain. Are there any other choices? Unfortunately, there is no wonder drug available. If the above therapeutic strategies fail, it might be worthwhile to send the patient to a referral hospital that has dedicated pain therapists. Otherwise, strong opioids would be an alternative, if available. If none of these alternatives apply, guiding the patient with tender loving care and explaining the usual limited time of intense pain are suggested. Never tell a patient that you cant do anything for him. So, what can an experienced pain therapist or regular anesthesiologist o er the patient? Th e therapy of choice in such incidences is regional anesthesia using epidural catheters. Th is technique is usually applied for major surgery or certain surgical

Management of Postherpetic Neuralgia procedures, when no general anesthesia is possible or necessary. Th ese epidural catheters may be inserted at almost all levels (cervical, thoracic, or lumbosacral). If the head or upper neck region is a ected, then epidural analgesia will not succeed. Th ere is no evidence that regional anesthesia shortens the course of acute zoster or reduces the chances for PHN. Th erefore, such an invasive treatment would only be justi ed with refractory excruciating pain, in order to control pain for a limited time period until the spontaneous reduction of pain occurs. Regional sympathetic chain blocks, for example at the stellate ganglion or at the thoracic or lumbar sympathetic chain, are usually only possible as one-time injections, and therefore do not control pain for more than a couple of hours. Th ese techniques have their use in PHN at a specialized pain clinic when there is evidence that the pain is sympathetically maintained.