Painful Diabetes

diabetes pain management

By Renee Wickliff BSN, RN, RD, CDCES

As if having a diagnosis of diabetes isn’t a big enough pain, complications of diabetes can cause actual, physical pain. Chronic high blood sugar is toxic to your nerves. It can cause diabetic neuropathy, which means damage to your nerves.

Diabetes Becomes Painful

               When your nerves become damaged, the type of pain you experience is known as neuropathic pain. This pain is distinct. You may experience burning, stabbing, or shooting pain with a tingling or crawling sensation [1]. Some patients describe it as bees stinging through socks or walking on hot coals. The pain is usually worse at night which can make it hard to sleep. The pain typically occurs in the feet and hands.

               Simple things, like a gentle touch or the sensation of a blanket against skin, can trigger the pain. Or it can occur spontaneously. Sensation to hot and cold may feel weird.

Pain Management with Medication

Pregabalin and duloxetine have been approved in the United States for treating neuropathic pain [1]. If you are already taking these drugs and still in a lot of pain, you may need to add another medication. The American Academy of Neurology also recommends the following medications that you can ask your doctor about:

  • Gabapentin 900–3600 mg/day
  • Duloxetine 60–120 mg/day
  • Amitriptyline 25–100 mg/day
  • Venlafaxine 75–225 mg/day
  • Sodium valproate 500–1200 mg/day
  • Dextromethorphan 400 mg/day
  • Morphine titrated to 120 mg/day
  • Tramadol 210 mg/day
  • Oxycodone 37 mg/day (max 120 mg/day)
  • Capsaicin, 0.075% four times a day
  • Isosorbide dinitrate spray

Over the counter medications that may help in the short term include nonsteroidal anti-inflammatory drugs or the NSAIDs [2]. Be careful about taking NSAIDs. The Mayo Clinic doesn’t recommend NSAIDs for diabetic neuropathy because of the risk of gastrointestinal hemorrhage, bleeding, and heart problems [3]. If you already have poor kidney function, NSAIDs can further damage your kidneys [2]. Don’t take NSAIDs if you take a blood thinner like warfarin (coumadin), heparin, or xarelto. This can cause bleeding.

The most common NSAIDs are aspirin, Aleve, Advil, and ibuprofen. Other NSAIDs include naproxen, Motrin, and nabumetone. Although they are over the counter and seem harmless, talk to your doctor before taking an NSAID.

Tylenol is another over the counter medication. It is not recommended by the Mayo Clinic because too much can cause liver damage [3]. However, liver damage typically only occurs if you take a lot for a long time. Do not take more than 4,000 mg a day and do not take more then 1,000 mg at one time. Tylenol can also falsely elevate blood sugar readings if you wear a continuous glucose monitor. The false reading can occur for up to 8 hours after taking Tylenol [4].

Anti-Seizure Medications

               Anti-seizure medications are frequently used to control diabetic pain. There are many different medications and they work in different ways. Some block different channels that may trigger pain, others may activate or inhibit different neurotransmitters involved in pain. Since they work in different ways, they can be combined for more effective pain management.

               Pregabalin is approved to treat diabetic neuropathy pain. In a study of 1,346 diabetic patients, the more pregabalin patients took, the better the pain control. Those taking 600 mg/day reported less pain then those taking 300 mg/day, who reported less pain then those taking 150 mg/day. And those taking 150 mg/day reported less pain then those taking the placebo. Side effects included dizziness, swelling, feeling tired, and headache [1]. An added benefit of pregabalin is that it helped people sleep.

               Doctors also frequently prescribe gabapentin to treat pain. A study with 135 diabetic neuropathy patients had them take gabapentin or a placebo for 8 weeks. Seventy patients took gabapentin and 65 took the placebo. Forty-seven patients in the gabapentin group reported that their health status “much improved” during the study compared to only 25 patients in the placebo. The gabapentin group also reported better sleep. About 20 people experienced the side effects of dizziness and tiredness while less then 10 had headache, diarrhea, confusion, and nausea [5].

Antidepressants for Pain Management

               New clinical trials show promise for using antidepressants to manage diabetic neuropathy pain. Antidepressants may interrupt the pain signals sent by damaged nerves.

               Tricyclic antidepressants include imipramine, amitriptyline, and clomipramine. Amitriptyline is not recommended if you have heart failure, a history of a heart attack, or other heart problems [1]. Tricyclic antidepressant drugs can have a lot of unwanted side effects, like causing abnormal heart rhythms and sudden drops in blood pressure (which can cause falls and injury).

               Serotonin-noradrenaline reuptake inhibitors, like duloxetine and venlafaxine, may be recommended instead of tricyclic antidepressants. Three studies looking at 60 to 120 mg doses of duloxetine over 12 weeks found that patient’s had less pain compared to placebo groups [1]. Most side effects were mild, including nausea, dizziness, tiredness, and constipation.

Another study looked at venlafaxine. Patients were given doses of 150 to 225 mg of venlafaxine, 75 mg of venlafaxine, or a placebo over 6 weeks. The group taking the highest dose of venlafaxine saw the greatest improvement in pain and the group taking the placebo saw the least improvement in pain.  


               Tramadol is an opioid that can be used to treat pain. It is a weak opioid and it is rare for it to be abused. Often, with stronger opioids, you need to take more and more to get the same effects. This doesn’t appear to be the case with tramadol [1].

               In a small study of 131 patients with painful diabetic neuropathy, half the group received 210 mg a day of tramadol or a placebo. At the end of the 6-week study, the group taking tramadol reported better pain scores. They also felt better physically and were able to engage in more social events then the placebo group [6].

Other Medications for Pain

An infusion of 600 mg α-lipoic acid a day improved pain of diabetic patients after 3 weeks. Another study gave diabetics 600 mg of α-lipoic acid to take by mouth or a placebo and found an improvement in pain scores. This finding has been replicated in other studies as well [1].

Capsaicin, found in red peppers, can be applied to the skin in the form of a cream. There is a 0.075% capsaicin cream available. One side effect of the cream is that it can cause a mild burning sensation, which occurs in more than 50% of cases. It is recommended not to use capsaicin cream for longer than 8 weeks because it can cause numbness in your nerve endings, which may increase the risk of developing diabetic foot ulcers [1].

Treating Pain Without Medication

               Acupuncture is a safe way to manage diabetic pain. Over a course of 10 weeks, 46 diabetic patients with painful neuropathy had 6 sessions of acupuncture. At the end of the study, 34 felt their pain improved and of that 34, 7 reported their pain was gone. Acupuncture did not have any harmful side effects in any of the patients [7].

               Transcutaneous electrical nerve stimulation (TENS) uses a low voltage electrical current to provide pain relief. Electrodes are placed on the skin near the pain or at trigger points. One theory of how TENS works is that the electric stimulation blocks pain signals. Another theory is that electrical stimulation raises endorphins. Endorphins are a natural pain-killing chemical in the body and help block the feeling of pain [8].

               In a 4-week study, when TENS was applied to the lower limbs for 30 minutes each day, 83% reported an improvement in pain compared to 38% of the placebo group. Although TENS would not be considered a first line treatment for pain, the American Academy of Neurology does recommend TENS if other treatments have failed [1].

               If you are having pain from things that should not be painful, like wearing clothes or your blanket in bed, try switching to silk pajamas and/or purchase a bed cradle. A bed cradle can lift sheets off your feet to reduce painful stimulation. You may want to visit a podiatrist to purchase comfortable, diabetic friendly shoes.

Talking to Your Doctor

               Painful diabetes is a common problem. Pain can negatively impact your life, making it difficult to sleep at night. Activities you normally enjoy may become difficult. You may feel tired a lot and start skipping spending time with family and friends. Anxiety and depression often accompany pain. Discuss the symptoms you are having with your doctor to figure out a treatment plan. No one deserves to suffer.


[1] A. I. Vinik and C. M. Casellini, “Guidelines in the management of diabetic nerve pain: clinical utility of pregabalin,” Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy , February 2013. [Online]. Available:
[2] S. Javed, I. N. Petropoulous, U. Alam and R. A. Malik, “Treatment of painful diabetic neuropathy,” Therapeutic Advances Chronic Disease, January 2015. [Online]. Available:
[3] K. Cohen, N. Shinkazh, J. Frank, I. Israel and C. Fellner, “Pharmacological Treatment Of Diabetic Peripheral Neuropathy,” Pharmacy and Therapeutics, June 2015. [Online]. Available:
[4] E. M. Tucker, “Acetaminophen (Tylenol) Elevates CGM Blood Glucose Results,” Diabetes Forecast, January 2016. [Online]. Available:
[5] M. Backonja, A. Beydoun, K. R. Edwards, S. :. Schwartz, V. Fonseca, M. Hes, L. LaMoreaux and E. Garofalo, “Gabapentin for the Symptomatic Treatment of Painful Neuropathy in Patients With Diabetes Mellitus,” Journal of the American Medical Assoication, 2 December 1998. [Online]. Available:
[6] Y. Harati, G. M. Swenson, S. Edelman, D. Greene, P. Raskin, P. Donofrio, D. Cornblath, R. Sachdeo, C. O. Sui and M. Kamin, “Double-blind Randomized Trial of Tramadol for the Treatment of the Pain of Diabetic Neuropathy,” Neurology, June 1998. [Online]. Available:
[7] B. B. Abuaisha, J. B. Costanzi and A. J. Boulton, “Acupuncture for the treatment of chronic painful peripheral diabetic neuropathy: a long-term study,” Diabetes Research and Clinical Practice, February 1998. [Online]. Available:
[8] Cleveland Clinic, “Transcutaneous Electrical Nerve Stimulation (TENS),” Cleveland Clinic, 2020. [Online]. Available:

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