NICE vs SIGN: Management of Neuropathic Pain (2025)
This guideline provides a comparative overview of the National Institute for Health and Care Excellence (NICE) Clinical Guideline CG173 (published 2013, last updated 2020) and the Scottish Intercollegiate Guidelines Network (SIGN) Guideline 155 on the management of chronic pain (published 2019), with a specific focus on neuropathic pain. Both guidelines aim to standardise and improve care, but they differ in scope, structure, and some key recommendations. This comparison is intended to aid UK clinicians in navigating these differences for informed, patient-centred decision-making.
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Diagnosis and Assessment
Accurate diagnosis is the cornerstone of effective management. Both guidelines emphasise the importance of a thorough clinical history and examination but differ in their recommended assessment tools.
NICE CG173
- Focus: Specifically on neuropathic pain.
- Diagnostic Approach: Recommends using validated screening tools to identify a neuropathic component. The guideline specifically mentions the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) scale or similar tools (e.g., DN4, PainDETECT).
- Assessment: Stresses assessing the impact of pain on mood, sleep, and daily function. It advises referral to a specialist pain service or a relevant clinical specialty if the diagnosis is uncertain or management is complex.
SIGN 155
- Focus: Broader, covering all chronic pain (including nociceptive, neuropathic, and nociplastic), with neuropathic pain as a subset.
- Diagnostic Approach: Also advocates for the use of validated tools but presents this within a broader biopsychosocial framework. It highlights the IASP grading system for neuropathic pain (definite, probable, possible) as a useful diagnostic framework.
- Assessment: Places a stronger emphasis on a comprehensive assessment that includes psychological and social factors from the outset. It recommends assessing for depression, anxiety, catastrophising, and social support as integral parts of the initial evaluation.
Key Difference: NICE is more direct in recommending specific screening questionnaires primarily for neuropathic pain identification. SIGN embeds the assessment of neuropathic pain within a holistic, biopsychosocial model for chronic pain, mandating a broader psychological and social assessment initially.
Pharmacological Treatment
This is the area with the most significant divergence between the guidelines, particularly regarding first-line therapy.
NICE CG173
- First-line: Offers a choice between amitriptyline, duloxetine, gabapentin, or pregabalin.
- Sequencing: If the first choice is not effective or tolerated, switch to one of the other three first-line options.
- Second-line: Recommends combination therapy with two of the first-line drugs (e.g., amitriptyline with gabapentin) if monotherapy fails.
- Capsaicin 8% patch: Recommended for peripheral neuropathic pain, specifically if first-line treatments are ineffective or poorly tolerated.
- Opioids: Strongly advises against the use of opioids (except tramadol) for neuropathic pain, citing lack of evidence for long-term benefit and risk of harm. Tramadol is only recommended for acute rescue therapy, not routine long-term use.
SIGN 155
- First-line: Amitriptyline or pregabalin are recommended as initial pharmacological treatments.
- Sequencing: If first-line treatment fails, the guideline suggests considering duloxetine or gabapentin.
- Combination Therapy: Also recognises that combination therapy may be beneficial but presents it as an option alongside switching.
- Capsaicin 8% patch: Similarly recommended for peripheral neuropathic pain.
- Opioids: Takes a more cautious but slightly less prohibitive stance. It states that opioids should not be used routinely for chronic non-cancer pain but may be considered in specific circumstances with a clear plan and regular review. This includes a stronger warning about the risks of dependence and hyperalgesia.
Key Difference: The first-line treatment options. NICE presents four drugs as equal choices (amitriptyline, duloxetine, gabapentin, pregabalin), while SIGN prioritises amitriptyline or pregabalin, with duloxetine and gabapentin as second-line alternatives. This has significant practical implications for prescribing practice.
Non-Pharmacological and Interventional Treatments
Both guidelines advocate for a multimodal approach beyond medication.
NICE CG173
- Psychological Therapies: Recommends considering a course of a psychological therapy (e.g., CBT) in combination with pharmacological treatments.
- Physical Therapies: Advice is less specific, suggesting treatments like acupuncture or exercise only as part of a broader treatment plan, noting limited evidence.
- Interventional Procedures: Recommends against using nerve blocks for diagnosis, but suggests considering injection therapy (e.g., epidural) for radicular pain (sciatica). Spinal cord stimulation is recommended as an option for patients with chronic, severe neuropathic pain who have failed other treatments, following a specialist assessment.
SIGN 155
- Psychological Therapies: Strongly recommends offering psychological interventions as a core component of treatment for all chronic pain, based on stronger evidence within its broader scope.
- Physical Therapies: More positively recommends structured exercise programmes and physiotherapy.
- Interventional Procedures: Provides more detailed guidance on a wider range of interventions, reflecting its specialist focus. It is more cautious about spinal cord stimulation, recommending it only in the context of a multidisciplinary team (MDT) decision and as part of a research protocol or national audit where possible.
Key Difference: SIGN places a greater emphasis on non-pharmacological treatments as foundational elements, consistent with its biopsychosocial model. NICE integrates them but with a primary focus on pharmacological sequencing.
Special Situations
Trigeminal Neuralgia
- NICE: Recommends carbamazepine as first-line. If ineffective, consider seeking specialist advice.
- SIGN: Similarly recommends carbamazepine or oxcarbazepine as first-line, with a more detailed pathway for second- and third-line options (e.g., lamotrigine, baclofen, surgery).
Chronic Sciatica
- Both guidelines acknowledge the mixed (neuropathic/nociceptive) nature of the pain. Management generally follows the neuropathic pain pathway, with both mentioning the potential role of epidural injections.
Cancer-Related Neuropathic Pain
- Both guidelines state that the principles of neuropathic pain management apply. However, the context of palliative care means a more liberal approach to strong opioids may be appropriate, guided by palliative care or oncology specialists.
Practical Clinical Flow: A Synthesised Approach
For a UK clinician, a pragmatic synthesis of both guidelines might look like this:
- Assessment: Take a detailed history and examine the patient. Use a tool like LANSS or DN4 to confirm neuropathic features. (NICE). Concurrently, conduct a brief assessment of mood, function, and social impact (SIGN).
- Diagnosis & Education: Explain the diagnosis of neuropathic pain and set realistic expectations about treatment goals (pain reduction, not cure).
- First-line Pharmacological Treatment: Initiate treatment with amitriptyline (considering cost-effectiveness) or pregabalin/gabapentin (if amitriptyline is contraindicated, e.g., in cardiac disease, or poorly tolerated). Discuss the choice with the patient. (SIGN-leaning).
- Titration and Review: Start low, go slow. Review after 2-4 weeks for efficacy and side effects.
- Second-line/Sequencing: If first choice fails, switch to the alternative first-line agent (e.g., from amitriptyline to pregabalin) or consider duloxetine. (SIGN). Alternatively, consider combination therapy (e.g., amitriptyline + gabapentin) at this stage. (NICE).
- Non-Pharmacological Integration: At any stage, but ideally early, consider referral for CBT or a structured exercise programme. (SIGN).
- Specialist Referral: Refer to a specialist pain service or neurology if diagnosis is uncertain, treatments are ineffective, or the pain is severe/complex. Consider interventions like the capsaicin 8% patch or spinal cord stimulation in a specialist setting.
Frequently Asked Questions (FAQs)
1. Which guideline should I follow in England? In Scotland?
Formally, NICE guidelines are the standard for England and Wales, while SIGN guidelines are for Scotland. However, both are respected across the UK. Clinicians should be aware of the local formulary and commissioning policies. In practice, many Scottish Health Boards use SIGN, while in England, NICE holds more weight for commissioning decisions.
2. Why is there a difference in first-line drug recommendations?
The differences stem from the interpretation of the same evidence base. NICE's broader first-line list (2013) aimed to offer flexibility and patient choice. SIGN's 2019 update, informed by newer evidence on relative efficacy and harms, sought to provide a more streamlined and potentially safer hierarchy, particularly emphasising caution with duloxetine's side-effect profile and gabapentin's pharmacokinetics.
3. How should I manage a patient on long-term opioids for neuropathic pain?
Both guidelines discourage initiating opioids for neuropathic pain. For patients already on long-term therapy, a cautious, patient-centred approach is essential. Discuss the lack of evidence for long-term benefit and the risks. Agree on a plan for gradual dose reduction (dose tapering) if appropriate, with close support and monitoring for withdrawal or pain exacerbation. Seek specialist pain team input.
4. What is the role of topical treatments like lidocaine plaster?
NICE recommends considering the lidocaine medicated plaster for localised peripheral neuropathic pain (e.g., post-herpetic neuralgia). SIGN also recognises its use, particularly where systemic side effects from oral medications are a concern. It is generally considered a useful option for elderly patients or those with comorbidities.
5. How urgently should I refer to a specialist pain service?
Referral should be considered if the diagnosis is unclear, if first- and second-line pharmacological treatments have failed after adequate trials, if the pain is severe and significantly disabling, or if there are complex psychological comorbidities. Neither guideline sets a strict timeline, emphasising clinical judgement.
Source Links
- NICE Clinical Guideline CG173 (Neuropathic pain in adults: pharmacological management in non-specialist settings): NICE CG173 (Published November 2013, last updated April 2020).
- SIGN Guideline 155 (Pharmacological management of chronic pain in adults): SIGN chronic pain (PDF) (Published December 2019).
Disclaimer: This document is a comparative summary for educational purposes. Clinicians should refer to the full guidelines and consult local protocols for definitive clinical decision-making.