Are you struggling with pain in your feet, legs, or hands from diabetic neuropathy? This is an especially frustrating condition that is both under-assessed and undertreated. And for those that do seek relief, it’s typical to have to try many different treatments before hitting on a combination that works.

Diabetic neuropathy pain is exactly the sort of condition where you might need the wisdom of people that have been there before. We reviewed more than a hundred comments in our Facebook group and forum to get an idea of how our community, made up of regular people with diabetes, deals with this problem.

This article will explore both the mainstream science of neuropathy pain mitigation and the everyday advice of Diabetes Daily community members.

What is Diabetic Neuropathy?

Diabetic neuropathy is a type of nerve damage common in people with diabetes. Neuropathy can affect many parts of the body, including the digestive system, the heart, the eyes, the bladder, the sweat glands, and sexual organs.

The nerve damage that mostly affects the feet, hands, legs, and arms is referred to as peripheral neuropathy. This condition is often very uncomfortable, with patients feeling pain, tingling, burning, prickling, numbness, and complete loss of feeling in the extremities. The pain may be worse at night. These symptoms are generally noticed first in the feet.

Diabetic neuropathy, like other diabetes complications, is ultimately caused by chronic high blood sugars. If you’ve begun to notice the pain associated with this condition, you should visit your doctor or endocrinologist soon. Diabetic neuropathy may indicate that you are also at risk of other serious complications.

Blood Sugar Control

If there’s one treatment for neuropathic pain that the Diabetes Daily community can wholeheartedly endorse, it is optimal blood sugar control.

Diabetic neuropathy is primarily caused by high blood sugar. Achieving a lower, healthier blood sugar is the best way to address the root cause of neuropathy, and may offer both short- and long-term relief. It is unclear if nerve damage can be reversed, but further damage can be prevented through superior blood sugar control.

If there’s another good reason to prioritize blood sugar control, it’s the fact that diabetic neuropathy is an early warning sign of some very dangerous diabetes complications. The feet of a patient with neuropathy may be less capable of healing wounds, which can ultimately “lead to limb compromise, local to systemic infection, and septicemia, and even death.” Several of our community members have had terrifying battles with septicemia.

Prescription Drugs

Don’t hesitate to speak to your doctor about prescription medication for this condition. Pharmaceuticals don’t work for everyone, but they might work for you.

In our community, the most popular pharmaceutical treatment seems to be gabapentin (Neurontin). Gabapentin is an oral prescription medication that acts on the brain, changing the way that it perceives pain. It is also used as an anti-convulsant, to prevent seizures in patients with epilepsy and related conditions.

Your doctor is likely to start you on a low dose, and you may need to increase that dose in order to feel an effect, or if the condition gets worse.

Gabapentin doesn’t work for everyone. A rigorous study found that only 35% of study participants enjoyed significant pain reduction, compared to 21% who were given a placebo, and that “over half of those treated with gabapentin will not have worthwhile pain relief.”

Gabapentin can have side effects, including skin issues, dizziness, and drowsiness. A small minority of users experience intense mood changes that may include suicidal thoughts.

Lyrica (pregabalin) may be the second most popular drug neuropathic pain in our community. Lyrica is related to gabapentin, belonging to the same class of anti-convulsants.

The evidence suggests that Lyrica and other pregabalins have a similar impact to gabapentin. A large review concluded that “Some people will derive substantial benefit with pregabalin; more will have moderate benefit, but many will have no benefit or will discontinue treatment.”

The American Academy of Neurology (AAN) officially recommends three other types of drugs for the treatment of diabetic neuropathy. These three are less commonly prescribed, and as a result, are less commonly discussed in our community:

• Serotonin-norepinephrine reuptake inhibitors (SNRIs), including duloxetine, venlafaxine, and desvenlafaxine. SNRIs are anti-depressants that are prescribed for a variety of mental health issues, including anxiety and obsessive-compulsive disorder. They can be effective in reducing neuropathic pain and, as a bonus, may improve mood and other quality of life factors.
• Tricyclic antidepressants (TCAs), such as amitriptyline, nortriptyline, and imipramine. TCAs are also anti-depressants, and have been used for decades. TCAs are considered “effective” in the treatment of neuropathic pain, but are associated with side effects, including weight gain.
• Sodium channel blockers (such as carbamazepine, oxcarbazepine, lamotrigine, valproic acid, lacosamide). Like gabapentinoids (including gabapentin and pregabalin), these drugs are used to prevent seizures. Sodium channel blockers are not often prescribed, perhaps due to the likelihood of side effects, but the AAN has concluded that they have a similar ability to reduce pain as the preceding drugs.

The AAN believes that the drugs named above are of roughly similar effectiveness, and that doctors should therefore make their recommendations based on “potential adverse effects, patient comorbidities, cost, and patient preference.”

The other important thing to note here is that none of these drugs is perfectly effective, and that doctors are completely unable to predict which drugs will work for which patients. Diabetic neuropathy is a mysterious condition, and experts don’t completely understand why drugs do and don’t work to reduce pain. It may take many months of experimentation with a series of pharmaceuticals to find a pill and a dose that works for you.

Finally, a word about opioids. These powerful painkillers are, in fact, the most commonly-prescribed treatment in the United States for diabetic neuropathy. However, they are not popular in the Diabetes Daily community. That may be for the best: experts from the AAN believe that the drugs should not be prescribed for this type of chronic pain. It seems that most doctors are unaware of that recommendation; a distressing 2020 study in the journal Pain found that most patients are prescribed opioids “before trying even one guideline-recommended medication for peripheral neuropathy,” and that far too many patients end up on chronic opioid therapy. The dreadful impact of opioid addiction is by now very well-known.

Mental Health and Sleep

It may sound surprising, but the American Academy of Neurology actually recommends that people with pain from diabetic neuropathy should seek treatment for sleep and mood disorders first, before they explore pain-relieving medication.

While mood or sleep improvements do not actually address the root cause of painful diabetic neuropathy, they do significantly alter our perception of pain.

It stands to reason that a well-rested and happy person is better equipped to deal with chronic pain. If that sounds too obvious, consider that people with diabetes suffer from both depression (and related mental health issues) and sleep disorders far more frequently than average, and that these conditions far too commonly go unrecognized and untreated.

The next time you see your healthcare provider, consider whether you should be discussing your sleep and mental health, in addition to your neuropathy pain and discomfort.

Topical Treatments

There is a bewildering variety of over-the-counter creams and sprays available for neuropathy pain. Experts are optimistic about the use of topical treatments, but scientific proof of their efficacy is a bit murky.

In the AAN guidance, four topical treatments were rated as “possibly more likely than placebo to improve pain.” Those treatments are:

• Capsaicin
• Nitrosense patches
• Citrullus colocynthis
• Glyceryl trinitrate spray

A different recent review identified many more chemicals that may be helpful, including even botox injections. This second review highlighted lidocaine and capsaicin patches as two therapies with particularly good data supporting their efficacy.

One brand that our community likes is Biofreeze, which uses menthol as its active ingredient. Biofreeze is available in many different application forms, including sprays, gels, patches, and wipes.

But to put it simply, nobody really knows which topical treatments work best, and what works for you may not work for someone else. It will probably take trial and error to find a product you like. We encourage you to work with your doctor to find good options.

Exercise

Exercise is a tricky subject for some people with neuropathic pain, because a workout itself may trigger that pain. There is also the fear that exercise is likely to cause problems for people with sensitive feet.

However, there is evidence that exercise is healthful for those damaged nerves. A 2014 review concluded that “it is critical to understand that routine exercise may not only help prevent some of those causes [of neuropathic pain], but that it has also proven to be an effective means of alleviating some of the condition’s most distressing symptoms.” And experts have argued that the benefits of exercise outweigh the risk of foot injuries.

Exercise can also be an important part of a holistic treatment plan for diabetic neuropathy. Even low-intensity exercise is known to help lower both blood sugar and cholesterol, prevent weight gain, and improve both mood and sleep, all of which means it will help combat both the root causes of neuropathic pain and your ability to tolerate pain.

Cannabis and CBD

When polling the Diabetes Daily community, perhaps the biggest surprise was how enthusiastically so many of our readers endorsed cannabis for neuropathic pain relief. Many have ranked it as their favorite way to alleviate or cope with the pain and discomfort.

Indeed, there is some evidence that cannabis can be effective. A small 2015 study found that “inhaled cannabis demonstrated a dose-dependent reduction in diabetic peripheral neuropathy pain.” A follow-up by the same team found a similar result.

Generally speaking, experts are somewhat hesitant. In 2021, the International Association for the Study of Pain announced that, due to a lack of good scientific evidence, it could not endorse the use of cannabis for pain relief. The organization also noted that there are important research gaps and much work to be done.

If medicinal-use cannabinoid products are allowed in your area, your doctor may be happy to write you a prescription. If adult-use cannabis is allowed, you don’t need a prescription. Nevertheless, please be aware that the legal status of cannabis use remains confusing in the United States. It is illegal at the federal level, but a gray area is increasingly emerging, for both medicinal and recreational use, as more and more states pass new legislature.

To learn more about cannabis and diabetes—including blood sugar effects and a special warning for patients with type 1 diabetes—please read our article, Marijuana and Diabetes, What You Need to Know.

Some of our community members also recommend CBD oil, either consumed or applied directly to the skin. Most medical authorities believe that the evidence in favor of CBD oil is extremely thin, and caution patients to be wary of anecdotes and marketing claims. Is CBD oil just snake oil? It’s impossible to say. Some of our community members believe it works, and there is some evidence that CBD oil can reduce neuropathic pain.

Elevating Feet

It is the feet, more than any other body part, that suffer most from peripheral neuropathy. Diabetes can lower the blood flow to the feet, which leads to all manner of issues, including slower wound healing and increased risk of infection.

Inadequate blood flow may contribute to nerve damage and pain in the feet. Elevating your feet may bring some pain relief.

When practical, put your feet up while sitting. Be sure to stand up, stretch your legs, and wiggle your feet and toes every once in a while. If the tingling, burning, and pain are at their worst when you’re in bed, experiment with elevating your feet by resting them on a pillow, even while you sleep.

Soaking Feet

Many people with diabetic neuropathy find fast relief from a good bath. Some go a step further, and include Epsom salts in their soaking ritual.

A 2020 study found that an electrical foot bath filled with saltwater offered significant pain reduction. (The warm water bath without salt had no effect).

But it is important to know that major diabetes authorities disagree with this advice, in part because a long soak may not be great for patients with vulnerable feet. The American Diabetes Association very plainly states: “don’t soak your feet.” If your feet are prone to slow-healing wounds, it may be wise to be careful with this remedy.

Compression Socks

Opinions differ on the wisdom of wearing compression socks. Some sources claim that these socks, which gently squeeze the lower legs, promote healthy blood flow. Others claim the exact opposite and say that compression socks restrict blood flow.

Compressions socks are most popular among people with diabetes that have foot and leg swelling issues. Studies have found that compression socks are effective in treating lower leg edema (swelling) without compromising circulation. We were not, however, able to find any published studies evaluating compression socks and pain from diabetic neuropathy.

Some of our community members find them useful for the treatment of neuropathic pain, but many experts think they’re a bad idea for people with diabetes. The National Institutes of Health tells people with diabetes foot issues: “do not wear tight socks.”

Alpha Lipoic Acid

Alpha lipoic acid (ALA) is a fatty acid and antioxidant that is found both in the human body and in many foods. It’s been proposed as an alternative treatment for many conditions, including neuropathic pain.

Several of our community members take ALA supplements (they should be easy to find in most pharmacies). ALA is theorized to improve “nerve blood flow, nerve conduction velocity, and several other measures of nerve function.” And there is some scientific evidence that ALA really does help to relieve neuropathic pain.

B Vitamins

B vitamins have a complex relationship with the human nervous system; too little or too much of certain B vitamins can directly cause nerve damage.

Some Diabetes Daily readers take a B vitamin supplement, and believe that it helps with their neuropathic pain. The science, though, is unclear. A review of 13 studies concluded that “the evidence is insufficient to determine whether vitamin B is beneficial or harmful,” but that the supplements were “generally well-tolerated.” There is some weak evidence that vitamin B12 may be helpful.

Massage

Whether they do it themselves, persuade a loved one, or hire a professional, several of our community members find relief from massage. Although the science on this isn’t exactly settled, a quick google search will show that there are many protocols out there for massage for pain relief from neuropathy.

We identified two studies that found significant pain reduction from aromatherapy massage, although it’s unclear if the aromatic oil or the massage was the critical element, or if they’re both necessary for relief. A 2016 study found that “Thai foot massage” achieved significant results, and a large 2019 meta-analysis found that Chinese acupressure massage, when combined with a Chinese medicinal footbath, also offered improvement.

Of course, you don’t really need a randomized controlled trial to know if a little foot rub feels good. This can be considered a nonpharmaceutical therapy with few downsides, one that is well worth a try.

When Nothing Works

Unfortunately, some of our community members have never found anything that helps relieve their pain. If that’s the case, we encourage you to re-prioritize blood sugar control and consider lifestyle changes that can promote stress reduction and good mental health.

There are also many resources out there for people that deal with chronic pain, such as the U.S. Pain Foundation, which has a wealth of information on coping mechanisms and self-management techniques. As the American Psychological Association states, “Mental and emotional wellness is equally important—psychological techniques and therapy help build resilience and teach the necessary skills for management of chronic pain.”

Takeaways

There are no easy answers for pain from diabetic neuropathy. Patients that do find some relief often use a combination of prescription medication, over-the-counter treatments, and non-medicinal techniques such as massage or foot elevation. Good blood sugar management is the only therapy that addresses the root cause.

If you have neuropathic pain, please seek treatment from a medical professional soon. The problem is better addressed sooner than later, and it may take some experimentation to find what works for you.

Read more about chronic pain, complications, foot pain, neuropathy, peripheral neuropathy.