Your guide to gabapentin for shingles

In this article:

• Gabapentin for shingles
• Efficacy for PHN
• Dosage
• Side effects
• Combining gabapentin with other treatments
• Contraindications
• The bottom line

In this article

• Gabapentin for shingles
• Efficacy for PHN
• Dosage
• Side effects
• Combining gabapentin with other treatments
• Contraindications
• The bottom line

Gabapentin is a prescription anticonvulsive medication prescribed to treat epilepsy, certain types of nerve pain, and restless legs syndrome. It’s often sold under the brand name Neurontin. While gabapentin isn’t typically used to treat the initial symptoms of shingles, it can provide some benefit for severe cases—and it is commonly used to treat nerve pain that persists beyond the acute stage of the illness, after the shingles rash has healed. Here’s what to know.

How does gabapentin work for shingles pain?

A shingles outbreak occurs when the dormant varicella-zoster virus (the same virus that causes chickenpox) suddenly activates, damaging parts of your nervous system and causing pain and inflammation. 

Although gabapentin was originally created to minimize seizure activity in people with epilepsy, it can also be an effective treatment for some types of neuropathic (nerve) pain, including the burning or tingling pain caused by shingles. Gabapentin can treat nerve pain by binding to specific proteins on nerve cells that reduce the excessive signaling that causes nerve pain,  according to Chelsea Lauro, DO, family medicine provider at Summit Health Family Medicine.

More commonly, gabapentin is prescribed to relieve pain that doesn’t improve after the shingles rash heals, but there is some evidence suggesting it may benefit people during the acute phase of illness as well. For example, a small study found that people over 60 years of age taking any amount of gabapentin during a shingles outbreak had more pain relief than those taking a placebo. 

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Is gabapentin effective for postherpetic neuralgia (PHN)?

There are two types of shingles pain: the acute pain during the outbreak and postherpetic neuralgia (PHN), explains Nadia K. Sirdar, MD, primary care provider and practice owner at Bethesda Modern Primary Care. During the acute stage of illness, shingles pain is common and often followed or accompanied by a telltale rash. Once the rash begins to crust over and clears, however, the pain usually subsides. 

When it doesn’t, it’s called postherpetic neuralgia (PHN). As many as 10% to 18% of people who experience a shingles outbreak develop PHN. It’s a type of chronic pain that can last for months after the shingles rash first appears, says Dr. Lauro, and is caused by nerve damage sustained during the acute shingles infection. PHN is often described as a burning, shooting, tingling, or shocking pain that either comes in waves or is persistent. It may also cause itching, numbness, or general sensitivity to touch or temperature changes. 

For the same reasons, gabapentin can provide nerve pain relief during an acute shingles infection; it also works to treat PHN. In fact, we have more evidence supporting gabapentin’s use after shingles. It’s considered a frontline treatment and one of only a few medications approved by the Food & Drug Administration (FDA) for PHN. 

A specialized form of gabapentin called Gralise, which is designed to stay in the stomach for longer and release the drug slowly, was approved in 2011 for use in treating PHN; one study found it reduced the average daily pain score in participants with PHN more than a placebo, in some cases, after just two days.

Other studies have found the standard immediate-release form of gabapentin to work well, too. For example, another study found that it significantly reduced PHN symptoms compared to a placebo and also helped participants sleep better.

Gabapentin dosage for shingles

Dr. Lauro says the typical dosage of gabapentin for shingles starts at 300 milligrams once daily and can be increased to 600 milligrams three times daily (for a maximum daily dose of 1,800 milligrams). However, she stresses that gabapentin dosing should always be assessed on a patient-by-patient basis since some people may need less.

For example, your provider may adjust your dose if you are older or have impaired kidney function. Your risk of gabapentin side effects is higher if your kidneys can’t filter out gabapentin at the typical rate.  

What to expect and how to manage side effects

Many people tolerate gabapentin well, but it does have some common side effects, including:

• Dizziness
• Drowsiness (somnolence)
• Weakness
• Diarrhea
• Dry mouth
• Swelling in the extremities
• Tremors and other uncontrolled movements

Dr. Sirdar says the adverse effects she sees most often in her clinical practice are drowsiness and loss of energy, or “generally feeling so tired it’s hard to get things done.” She adds that many of her older patients also report dizziness, and warns there is the possibility of a very serious drug reaction called DRESS syndrome, or Drug Reaction with Eosinophilia and Systemic Symptoms. DRESS syndrome is a medical emergency that needs to be treated immediately; symptoms include fever, rash, facial swelling, and abnormal kidney or liver tests.

If you’re experiencing more common gabapentin side effects like drowsiness and dizziness, Dr. Sirdar says it’s important to work closely with your healthcare provider to find the right dose for you (i.e.,  the minimum amount of medication that brings you relief without knocking you out). 

If gabapentin is making you sleepy, avoid driving after taking a dose. You may also need to figure out the best time to take a dose so it doesn’t interfere as much with your ability to work or be productive.  

“I personally had a shingles outbreak as a first responder during COVID and could not tolerate the gabapentin and still work my shift as a physician,” says Dr. Sirdar. “I powered through with Tylenol and Motrin, but [it wasn’t] super effective, and if I could take the gabapentin off-shift or in the evening, I would.”

To minimize side effects of gabapentin, you should also be sure to tell your provider about any medical conditions you have or other medications and supplements you take, as drug interactions can occur. People with kidney disease or reduced kidney function may also need lower doses, says Dr. Sirdar, because gabapentin is excreted through the urine. You also shouldn’t combine gabapentin with any opioid or narcotic pain relievers, she adds, because this increases your risk for respiratory depression (slowed or shallow breathing) that can be dangerous.  

Combining gabapentin with other treatments

There are several treatments you can safely combine with gabapentin to maximize your pain relief during and after a shingles outbreak. 

• During an acute outbreak, there is some evidence that combining gabapentin with the antiviral drug valacyclovir not only reduces short-term pain but also reduces the risk of developing PHN after the shingles rash has cleared. 
• During and after an outbreak, Dr. Sirdar often recommends topical analgesics such as lidocaine or capsaicin creams and patches.
• For people with PHN, Dr. Sirdar says tricyclic antidepressants (TCAs) like amitriptyline or nortriptyline may be an option. Experts think TCAs help relieve chronic nerve pain by increasing the levels of chemicals in the brain that help moderate pain signals. These medications have been shown in several studies to work effectively alongside gabapentin to treat PHN, especially in people who can’t tolerate high doses of gabapentin alone.  

When gabapentin might not be the best choice

Gabapentin can be a good choice for many people experiencing acute shingles pain or PHN, but it’s not right for everyone. If you experience intense or serious side effects while taking gabapentin, or if the risk of side effects is too high for you (because of other medical conditions or medications), it may be better to try managing your pain another way.

It’s also important to remember that not everyone achieves complete pain relief with gabapentin, says Dr. Lauro, so if you’re still having symptoms and experiencing side effects, there could be a better option.

The bottom line

Gabapentin can work to ease both acute shingles pain (during an outbreak) and chronic nerve pain that persists after the infection has otherwise healed. It’s commonly used to treat PHN in particular and can be combined with other treatments to improve pain management and minimize side effects. 

However, gabapentin can cause excessive drowsiness or dizziness, making it hard to drive, work, or go about your normal routine. It’s important to work closely with your healthcare provider to determine whether gabapentin is right for you and to share your medical history so they can help you find the right dose for your needs.