Introduction
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Introduction
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Acute and chronic
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Types of pain
Pain is an unpleasant sensation that can present, for example, as burning, pressure or dull pain and can affect different body regions. Pain can indicate tissue damage or a functional disorder and requires timely assessment and, if necessary, immediate treatment.
Patients often expect effective and comprehensive pain relief from the treatment team as an initial priority. This does not have to be achieved solely with medication: support, attention and conversations can also contribute. Although making the correct diagnosis is a central task of medical action, from the patients’ perspective pain relief often takes precedence. It contributes significantly to satisfaction with the treatment.
A thorough pain history includes:
- Location: Where do the pains occur?
- Onset and course: How long have the pains been present, and how have they developed?
- Radiation: Do the pains radiate to other body regions?
- Quality of pain: Are the pains, for example, burning, pressing, stabbing or dull?
- Pain intensity: How severe is the pain, for example on a scale from 0 to 10?
- Aggravating and relieving factors: What worsens or improves the pain?
- Previous episodes: Have similar pains occurred before?
- Previous measures: Which treatments have been tried, and how effective were they?
- Possible triggers: Is there an identifiable association with certain events or situations?
- Associated symptoms: What other complaints occur?
Acute pain occurs in connection with a current injury or disease and is usually time-limited. Pain is generally considered chronic when it has been present for longer than three months or recurs.
Acute pain can become chronic, for example in back pain. Conversely, chronic pain can show acute exacerbations, such as in chronic inflammatory bowel disease.
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Visceral
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Somatic
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Neuropathic
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Pain with psychological factors
Visceral pain arises from internal organs. It is often poorly localized and can be perceived as dull, pressing or colicky. Radiation to other body regions is possible.
Examples include pain from a myocardial infarction, nephrolithiasis or symptomatic cholecystolithiasis.
In severe pain, opioid analgesics may be used depending on the cause and situation.
Somatic pain arises, for example, in skin, muscles, bones or joints. It is often better localized and can worsen with movement or pressure.
Examples include pain from fractures, pharyngitis or osteoarthritis.
Depending on pain intensity and cause, non-opioid analgesics and, if necessary, opioid analgesics are used.
Neuropathic pain arises from damage to or disease of the somatosensory nervous system. Typical symptoms are burning, electric or shooting pains, often accompanied by tingling, numbness or increased sensitivity to touch.
Examples include postherpetic neuralgia, painful diabetic neuropathy and radicular pain, for example in sciatica.
Treatment options include gabapentinoids and certain antidepressants, for example tricyclic antidepressants.
Pain can occur in connection with psychological stressors or disorders or can be amplified by them. In examinations there is sometimes no physical finding that sufficiently explains the complaints. The pain is nevertheless actually experienced. Its intensity and presentation can fluctuate.
Psychological factors can play a role in all types of pain. Therefore, a lack of an explanatory organic finding does not automatically mean that the pain is solely psychological in origin.
Case examples
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Visceral
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Somatic
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Neuropathic
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with psychological contributing factors
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Right-sided renal colic
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Biliary colic
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Primary dysmenorrhea
A 43-year-old man, 82 kg, presents to the emergency department with right-sided flank pain that has persisted for 90 minutes. The pain is colicky, radiates into the right groin and reaches 9/10. He paces restlessly and has vomited once. Three years ago he already had a urinary stone. In his work in a large kitchen he often drinks little.
Physical examination: Blood pressure 146/88 mmHg, pulse 96/min, temperature 36,8 °C. Right-sided costovertebral angle tenderness; abdomen soft, no guarding. Clinically no relevant dehydration.
Laboratory: Creatinine 0,95 mg/dl, CRP 2 mg/l, leukocytes 8,9 G/l. Blood is detected in the urine, but there is no evidence of a urinary tract infection.
Further diagnostics: A low-dose CT without contrast shows a 4-mm stone in the distal right ureter with slight urinary obstruction.
Precautions: Renal function and fluid balance were checked. There is no history of peptic ulcer, relevant cardiovascular disease or anticoagulation. No additional NSAIDs are administered.
Initial treatment: Because of the vomiting the patient receives ketorolac 30 mg i.m. or i.v. A first pain relief is expected after about 30 minutes. As the pain does not subside sufficiently the treating physician first administers 2,5 mg morphine slowly i.v. under monitoring of respiration, oxygen saturation and circulation. Further dosing depends on individual response.
A 52-year-old woman, 91 kg, develops severe pain in the right upper abdomen after dinner. The complaints have been present for one hour, radiate under the right shoulder blade and reach 7/10. She has vomited twice. A similar episode occurred six weeks earlier. Her BMI is 33 kg/m²; her mother underwent surgery for gallstones.
Physical examination: Blood pressure 138/82 mmHg, pulse 88/min, temperature 36,7 °C. Tenderness on palpation in the right upper abdomen, no guarding, no definite Murphy’s sign and no jaundice.
Laboratory: Leukocytes 7,8 G/l, CRP 3 mg/l, bilirubin 0,7 mg/dl. ALP, GGT, transaminases, lipase and creatinine are within the reference range.
Further diagnostics: Ultrasound shows multiple gallbladder stones without wall thickening or dilation of the bile ducts.
Initial treatment: Because of the vomiting the patient receives diclofenac 50 mg rectally once. An effect is expected after approximately 30–60 minutes and lasts for several hours. Afterwards pain and abdominal findings are reassessed.
Precautions: There is no known history of peptic ulcer, NSAID intolerance or relevant cardiovascular disease. Other NSAIDs are not given concurrently. For further physician-ordered administrations the daily maximum dose is 150 mg.
Because of the recurrent symptomatic episode a surgical consultation is arranged after the colic subsides to plan a laparoscopic cholecystectomy.
A 23-year-old student, 61 kg, reports cramp-like lower abdominal pain since the start of her menstruation this morning. Pain intensity is 6/10. Since age 16 she has had similar complaints on the first two days of bleeding. She is symptom-free between menstruations. Her sister also has pronounced menstrual pain.
Physical examination: temperature 36,6 °C, pulse 76/min. Mild central lower abdominal tenderness, no guarding.
Laboratory: A urine pregnancy test performed for a possible pregnancy is negative. With normal bleeding and no signs of infection no further laboratory tests are ordered.
Further diagnostics: A gynecological examination including ultrasound performed three months ago for the same complaints was unremarkable. No new or atypical symptoms are present.
Initial treatment: The patient takes ibuprofen 400 mg p.o. If pain recurs she may repeat the dose with at least six hours interval, up to three times daily or 1.200 mg within 24 hours, for the first two days of bleeding.
Relief is expected after about 30–60 minutes and lasts approximately 4–6 hours.
Precautions: There is no renal disease, history of ulcers or NSAID intolerance. Other NSAIDs are not taken concurrently.
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Painful right knee in gonarthrosis
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Non-displaced distal radius fracture
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Acute viral pharyngitis
A 68-year-old woman, 84 kg, complains of increasing pain in the right knee for six months. When climbing stairs it reaches 5/10; at rest there is little discomfort. After prolonged sitting the first steps are painful. Morning stiffness lasts ten minutes. Fifteen years ago she had surgery on the right meniscus.
Physical examination: medial joint space tenderness, crepitus and limited flexion to 110°. No redness, marked warmth or significant effusion.
Laboratory: In the absence of indications for an inflammatory or infectious joint disease no laboratory tests are ordered.
Further diagnostics: An existing X-ray shows medial joint space narrowing and osteophytes.
Initial treatment: The patient begins targeted exercise therapy with physiotherapy twice weekly for 30 minutes over six weeks. In addition she performs the learned exercises daily for about ten minutes. The focus is on quadriceps strengthening and improving knee mobility.
A functional improvement is expected over several weeks. The exercises are then continued regularly.
As pharmacological therapy a topical NSAID, for example diclofenac gel, can be used. If effect is insufficient or symptoms are more pronounced, oral NSAIDs may be considered after assessment of gastrointestinal, renal and cardiovascular risks.
Precautions: Because of her previous inactivity the load is started low and gradually adjusted. If new significant swelling or increased warmth occurs the knee is re-examined.
A 58-year-old woman, 64 kg, falls onto her outstretched left hand. On presentation the pain is 5/10. She has known osteoporosis.
Physical examination: swelling and tenderness over the distal radius, no open wound. Finger movement, sensation and perfusion are preserved before and after application of the splint.
Laboratory: In uncomplicated conservative management no acute laboratory tests are necessary.
Further diagnostics: The X-ray shows an extra-articular, non-displaced distal radius fracture.
Initial treatment: The radius fracture is immobilized. If pain remains severe the patient initially receives morphine 2 mg slowly i.v. Pain relief begins within a few minutes. Respiratory rate, oxygen saturation, blood pressure and level of consciousness are monitored. After adequate pain control, if further analgesia is required, conversion to oral non-opioid analgesia is made.
Precautions: There is no liver disease. No additional paracetamol-containing preparations are taken. Increasing pain, numbness or cold fingers under the splint prompt immediate re-examination.
An orthopedic trauma follow-up is arranged.
A 28-year-old teacher, 74 kg, presents with sore throat of two days’ duration. Pain on swallowing reaches 5/10. He additionally reports a runny nose and dry cough. Several children in his class have colds. He can drink fluids adequately.
Physical examination: temperature 37,6 °C, pulse 80/min. The pharyngeal mucosa is reddened, the tonsils are not markedly enlarged and show no exudates. No tender anterior cervical lymph nodes. The uvula is midline; no trismus, muffled voice or dyspnea.
Laboratory: With a mild course and no indications of systemic infection neither blood count nor CRP are determined.
Further diagnostics: Rhinorrhea and cough together with the examination findings suggest a viral cause. A rapid streptococcal test or throat swab is not performed in this case.
Initial treatment: For pain relief the patient takes ibuprofen 400 mg p.o. If needed he may repeat the dose with at least six hours interval, up to three times daily or 1.200 mg within 24 hours, initially for two days. Initial relief is expected after approximately 30–60 minutes; the effect lasts about 4–6 hours. Antibiotic therapy is not indicated in this case.
Precautions: The patient has no history of ulcers, renal disease or NSAID intolerance and is not taking anticoagulants. Other NSAIDs are not taken concurrently. If dyspnea, inability to drink, increasing unilateral symptoms or marked deterioration occur a re-examination is performed.
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Painful diabetic polyneuropathy
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Localized postherpetic neuralgia
A 62-year-old man, 86 kg, has had type 2 diabetes mellitus for 16 years. For four months he has had bilateral burning foot pain, at night up to 7/10. The bedcover is perceived as painful. At the same time the toes feel numb.
Physical examination: stocking-shaped reduced touch and vibration sensation and diminished Achilles tendon reflexes. No wounds; foot pulses palpable.
Laboratory: HbA₁c 8,6 %, eGFR 78 ml/min/1,73 m². Vitamin B₁₂, TSH and liver values unremarkable.
Further diagnostics: The symmetrical findings are consistent with diabetic polyneuropathy. With a typical course and no motor deficits no electroneurography is initially performed.
Initial treatment: The patient starts duloxetine 60 mg p.o. once daily. His blood pressure is 128/78 mmHg. No relevant liver disease or serotonergic concomitant medications are present.
An initial effect is possible already in the first week. Tolerability and blood pressure are checked after two weeks, and the pain course after four weeks. Duloxetine is taken regularly and not on demand.
Precautions: Nausea, dizziness and a possible increase in blood pressure are discussed. When later discontinuing the drug it is tapered.
In parallel diabetes management and daily foot inspection are optimized.
A 73-year-old woman, 67 kg, continues to suffer burning pain of the lateral chest wall four months after a left-sided shingles. On contact with clothing the pain reaches 6/10. The affected area is approximately the size of a palm. Because of previous falls she prefers to avoid additionally sedating medication if possible.
Physical examination: Completely healed skin, localized allodynia in the previously affected dermatome and slight hypoesthesia. No new vesicles.
Laboratory: No additional laboratory tests are requested for the clinically clear diagnosis.
Further diagnostics: Because of the typical temporal and local correlation imaging is not required.
Initial treatment: The patient uses a lidocaine patch 5 % applied topically over the painful area. It is applied in the evening and removed after at most twelve hours. This is followed by at least twelve hours without a patch.
Relief may occur during use. Benefit is assessed after two to four weeks. If ineffective the treatment is reviewed.
If pain relief is insufficient gabapentin is additionally prescribed. With normal renal function the patient starts with 300 mg in the evening on the first day, takes 300 mg morning and evening on the second day and from the third day 300 mg three times daily. Further dose increases depend on effect and tolerability. In older or frail patients titration is slower; in impaired renal function the dose is adjusted.
Precautions: The patch is applied exclusively to intact, healed skin. It is removed in case of marked skin irritation. An allergy to lidocaine is not known.-
Fibromyalgia syndrome
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Chronic neck pain with stress amplification
A 44-year-old woman reports pain in the shoulder girdle, back and in the arms and legs for 14 months. She also has fatigue and non-restorative sleep. After stressful workdays the complaints increase. She has increasingly stopped physical activities.
Physical examination: diffuse tenderness, no joint swelling, no objective muscle weakness and no focal neurological deficits.
Laboratory: blood count, CRP, TSH and CK unremarkable.
Further diagnostics: The clinical assessment of pain distribution, duration and accompanying symptoms indicates fibromyalgia syndrome. There are no concrete signs of an additional inflammatory or neuromuscular disease.
Initial treatment: The patient begins an individually tailored, supervised exercise program. In the first two weeks she walks three times weekly for ten minutes at a well-tolerated pace. With good tolerability the volume is gradually adjusted together.
The course is assessed after six weeks. Goals are improved endurance and daily function. Immediate freedom from pain is not expected.
Precautions: A marked, persistent worsening leads to adjustment of the program. Fibromyalgia is not classified as an exclusively psychologically caused disease.
In cases of severe pain and sleep disturbance, amitriptyline can be used in addition to exercise and other non-pharmacological measures. Treatment starts, for example, with 10 mg p.o. at night. With good tolerability and insufficient effect it can be increased after one to two weeks to 25 mg at night. Use in fibromyalgia is generally off-label; appropriate counseling is required.
A 36-year-old teacher reports neck and shoulder girdle pain for seven months. On teaching days it reaches 5/10, often only 2/10 on weekends. She sits at the computer late in the evening, sleeps poorly and notices that she raises her shoulders when tense.
Physical examination: tender shoulder girdle muscles and slightly restricted cervical spine rotation. No arm pain, pareses, sensory disturbances or reflex abnormalities.
Laboratory: With no indications of a systemic disease no laboratory tests are ordered.
Further diagnostics: In the absence of red flags and with an unremarkable neurological examination no imaging is initially performed.
Initial treatment: The patient begins a supervised movement and strengthening program twice weekly for 30 minutes over six weeks. She performs the learned exercises for shoulder girdle and neck additionally daily for five to ten minutes. During lesson preparation she takes short movement breaks.
The effect is assessed after six weeks based on pain, mobility and endurance.
Precautions: With a marked increase in complaints the training is adjusted. New onset weakness or numbness in the arm leads to a re-examination.
Special pain therapy
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Migraine attack
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Trigeminal neuralgia
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Acute gout attack
Typical case: A 32-year-old woman has had right-sided, pulsating headaches since the morning with nausea and photophobia. Physical movement worsens the complaints. Comparable attacks have been known for several years. Ibuprofen has not been sufficiently effective this time. Neurological examination and blood pressure are unremarkable.
Treatment options: Sumatriptan can be used as a tablet, nasal spray or subcutaneous injection. The formulation is chosen particularly according to vomiting and desired speed of onset. The following dosages apply to adults.
Oral treatment: As the patient is not vomiting she initially takes sumatriptan 50 mg p.o., for example Imigran 50 mg. An initial effect may occur after approximately 30 minutes. If the symptoms initially subside and later recur another 50 mg may be taken after at least two hours. For the mentioned prescription product the maximum dose is 300 mg within 24 hours. If there is a complete lack of effect no second dose is taken for the same attack.
Nasal spray: For pronounced nausea or vomiting, sumatriptan 20 mg intranasal, for example Imigran Nasal 20 mg, may be considered. A single dose is sprayed into one nostril. An initial effect can occur after approximately 15 minutes. If the treatment is initially successful and symptoms recur, a further dose may be given no sooner than two hours later. At most two single doses of 20 mg each within 24 hours. If there is a complete lack of effect, no second dose is used for the same attack.
Subcutaneous injection: For a particularly severe attack, repeated vomiting or when rapid effect is required, sumatriptan 6 mg s.c., for example Imigran-Inject, can be used. An initial effect may occur after approximately 10–15 minutes. If the pain subsides initially and then recurs, a further injection of 6 mg is possible no sooner than one hour later. Maximum 12 mg within 24 hours. If there is a complete lack of effect, no second injection is given for the same attack. Do not administer intravenously.
Side effects: Possible are dizziness, fatigue, tingling, a sensation of warmth and a transient feeling of pressure or tightness. Pronounced or persistent chest pain requires immediate evaluation.
Contraindications and precautions: Sumatriptan must not be used in patients with coronary artery disease, previous stroke or TIA, peripheral arterial occlusive disease, uncontrolled hypertension and severe hepatic impairment, among others. No concomitant use with other triptans or ergotamines; observe prescribed dosing intervals. Treatment with MAO inhibitors may also exclude use.
Typical case: A 61-year-old woman describes second-long, electric-shock-like pains in the right cheek and lower jaw. Toothbrushing and chewing trigger the attacks. Between attacks she is largely symptom-free. Dental examination finds no cause. Neurological workup including MRI has been performed.
Treatment: The patient starts carbamazepine, for example Tegretal 200 mg tablets.
Dose and repetition: Initially she takes 100 mg p.o. in the morning and 100 mg p.o. in the evening, corresponding to half of a divisible 200-mg tablet. If attacks persist the dose is slowly increased under medical supervision, often to a total of 400–800 mg daily, divided over several doses. Carbamazepine is taken regularly and is not suitable as a single on-demand dose during an attack.
Side effects: Possible are fatigue, dizziness, diplopia, gait instability and hyponatremia. Rarely severe skin reactions, hematological changes or liver damage occur.
Contraindications and precautions: Contraindications include, among others, AV block, previous bone marrow suppression, certain porphyrias and concurrent or recently completed treatment with MAO inhibitors. Before and during treatment, blood count, liver tests and sodium are monitored. Numerous drug interactions must be considered, including with hormonal contraceptives and anticoagulants. Rash, fever or mucosal changes must be assessed by a physician immediately.
Typical case: A 52-year-old man develops during the night severe pain in the right first metatarsophalangeal joint. The joint is red, warm and swollen. Comparable attacks are known; a previous joint aspiration demonstrated urate crystals. He has no fever. Renal function, liver tests and blood count are unremarkable.
Treatment: One possible treatment is colchicine, for example Colchicin-ratiopharm 0,5 mg Tabletten.
Dose and repetition: The patient takes 0,5 mg p.o. in the morning and 0,5 mg p.o. in the evening, initially for two days. If symptoms persist and tolerability is good, treatment is continued on the third day. Once the attack has subsided, it is stopped. If there is no improvement after two to three days, the treatment must be re-evaluated. For the named preparation the maximum dose is 6 mg per treatment cycle. A new cycle may begin no earlier than 72 hours after the end of the previous one.
Side effects: Diarrhea, nausea, vomiting and abdominal pain can be signs of evolving toxicity. In this case colchicine is stopped immediately and medical evaluation is arranged. Rarely severe hematological changes or muscle damage occur.
Contraindications and precautions: Do not use in severe renal or hepatic impairment or existing hematological disorders. Dangerous interactions exist particularly with clarithromycin, certain azole antimycotics, ciclosporin and other CYP3A4 or P-glycoprotein inhibitors. In mild to moderate renal or hepatic impairment the dose for this preparation must be reduced.
Therapy
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Non-opioid analgesics
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NSAIDs
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Topical NSAIDs
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Opioid analgesics
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Gabapentinoids
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Antidepressants
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Local anesthetics
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Selective COX-2 inhibitors
| Active ingredient | Brand names | Forms | Typical strengths | Single dose and administration | Daily dose / Maximum | Important side effects | Contraindications and precautions | Indications | Type of pain |
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| Paracetamol | ben-u-ron; Paracetamol-ratiopharm; Perfalgan | Tablets, suppositories, syrup, infusion solution | Tablets: 500/1,000 mg; infusion: 10 mg/ml | p.o.: 500–1,000 mg, usually at least 6 hours apart. i.v.: 1,000 mg over 15 minutes in patients >50 kg; at least 4 hours interval | Product-dependent maximum usually 3–4 g/day; less with risk factors. Sum all routes of administration | Especially severe liver injury with overdose; rare severe skin or allergic reactions | Severe liver dysfunction; dose adjustment with liver risks, malnutrition or low body weight. In severe renal insufficiency, longer intervals | Mild to moderate acute pain; adjunctive postoperative or posttraumatic analgesia | Nociceptive, predominantly somatic |
| Metamizole | Novalgin; Novaminsulfon-ratiopharm; Metamizol HEXAL | Tablets, drops, suppositories, injection solution | Tablets: 500 mg; drops and injection solution often 500 mg/ml | p.o.: 500–1,000 mg every 6–8 hours in adults >53 kg. Parenteral dosing set separately; i.v. slowly and under monitoring | Oral maximum 4,000 mg/day. Parenteral maxima depend on the specific product | Agranulocytosis, anaphylaxis, blood pressure drop; rare liver injury | Previous metamizole-induced agranulocytosis, relevant hematopoietic disorders, certain analgesic intolerances; last trimester of pregnancy. If fever, sore throat or mucosal lesions occur, stop immediately and check blood count | Severe postoperative, posttraumatic and cancer pain; colic; other severe pain when alternatives are unsuitable | Nociceptive, somatic and visceral |
| Active ingredient | Three brand names | Forms | Typical strengths | Single dose and administration | Daily dose / Maximum | Important side effects | Contraindications and precautions | Indications | Type of pain |
|---|---|---|---|---|---|---|---|---|---|
| Ibuprofen | Nurofen; Dolgit; Ibu-ratiopharm | Tablets, capsules, suspension, suppositories | 200/400/600/800 mg | Short-term analgesia usually 200–400 mg p.o.; with 400 mg at least 6 hours interval. Higher single doses may be prescribed by a physician if indicated | OTC maximum 1,200 mg/day; with appropriate indication by a physician up to 2,400 mg/day | Gastric complaints, ulcers, bleeding, kidney damage, edema, blood pressure increase | Active or recurrent ulcers, relevant bleeding, severe organ insufficiency, NSAID allergy; last trimester of pregnancy. Caution with dehydration and anticoagulation | Dysmenorrhea, muscle and joint pain, injury pain, painful pharyngitis | Nociceptive, somatic and partly visceral |
| Diclofenac | Voltaren; Diclac; Diclofenac-ratiopharm | Tablets, sustained-release formulations, suppositories; injections depending on product | Immediate-release: 25/50 mg; sustained-release: e.g. 75/100 mg; suppositories: 50/100 mg | For example 25–50 mg p.o. or 50 mg rectally. Frequency depends on product and course | Systemic maximum usually 150 mg/day | Gastrointestinal bleeding, renal dysfunction, elevated liver enzymes, edema; increased arterial thrombosis risk | Among others ulcers, severe organ insufficiency, known coronary artery disease, peripheral arterial disease, cerebrovascular disease or heart failure NYHA II–IV; last trimester of pregnancy | Renal and biliary colic; inflammatory and degenerative joint complaints | Nociceptive, somatic and visceral |
| Naproxen | Dolormin für Frauen; Dolormin GS; Naproxen-CT | Tablets | 250/500 mg | Often 250–500 mg p.o., e.g. twice daily. Acute and OTC regimens depend on the product | OTC for some products maximum 750 mg/day; physician-prescribed often 500–1,000 mg/day. Certain acute regimens allow up to 1,250 mg/day short-term | Ulcers and bleeding, renal dysfunction, edema, blood pressure increase | NSAID contraindications; particular caution with gastrointestinal risk, renal insufficiency and anticoagulation | Dysmenorrhea, arthritis, osteoarthritis complaints, acute gout attack according to product authorization | Nociceptive, somatic and partly visceral |
| Dexketoprofen | Sympal; Keral; Enantyum — partly international names | Tablets, granules or oral solution; injection/infusion solution | Oral: 25 mg; parenteral: 50 mg/2 ml | p.o.: 25 mg every 8 hours or 12.5 mg every 4–6 hours. Parenteral: 50 mg every 8–12 hours if needed | Oral maximum 75 mg/day; parenteral maximum 150 mg/day, usually for max 2 days. Lower limits in elderly or organ dysfunction | Nausea, abdominal pain, ulcers, bleeding, kidney damage | NSAID contraindications; with impaired renal or hepatic function product-dependent restrictions. Not for uncritical long-term use | Short-term acute muscle, dental, menstrual and postoperative pain | Nociceptive, somatic and visceral |
| Ketorolac | Toradol; Droal; Tonum — international products | Injection solution; internationally also tablets | Injection often 30 mg/ml; tablets: 10 mg | According to the UK Toradol product information initially 10 mg i.v./i.m., then 10–30 mg every 4–6 hours as needed | In this regimen maximum 90 mg/day; in older patients, impaired renal function or <50 kg maximum 60 mg/day. Parenteral use max 2 days | Especially gastrointestinal bleeding risk, kidney damage, bleeding tendency | Ulcer or gastrointestinal bleeding history, relevant renal insufficiency, volume depletion and increased bleeding tendency; no other NSAIDs. Observe national licensing | Short-term acute pain, particularly postoperative according to local authorization | Nociceptive, somatic and visceral |
| Active ingredient | Three brand names | Forms | Typical strengths | Single dose and administration | Daily dose / Maximum | Important side effects | Contraindications and precautions | Indications | Type of pain |
|---|---|---|---|---|---|---|---|---|---|
| Diclofenac | Voltaren Schmerzgel; Diclac Schmerzgel; Diclo-ratiopharm Schmerzgel | Gel | For example 1% diclofenac sodium or 1.16% diclofenac diethylamine; higher-concentration gels available | With low-concentration gels often 2–4 g cutaneously three to four times daily; higher-concentration products usually twice daily | Product-dependent; some low-concentration gels maximum 16 g gel/day | Skin redness, itching, contact dermatitis; systemic effects possible with large-area application | Do not apply to open or inflamed skin; consider NSAID allergy. No occlusive dressings; last trimester of pregnancy | Locally limited muscle, tendon and joint pain; osteoarthritis complaints per product authorization | Somatic-nociceptive |
| Active ingredient | Three brand names | Forms | Typical strengths | Single dose and administration | Daily dose / Maximum | Important side effects | Contraindications and precautions | Indications | Type of pain |
|---|---|---|---|---|---|---|---|---|---|
| Tramadol | Tramal; Tramagit; Tramadol-ratiopharm | Capsules, drops, sustained-release formulations, suppositories, injection solution | Immediate-release: 50 mg; sustained-release often 100/150/200 mg; drops often 100 mg/ml | Immediate-release 50–100 mg p.o. every 4–6 hours. Sustained-release formulations usually twice daily, product-dependent | Usually maximum 400 mg/day; in elderly or organ dysfunction possibly less or longer intervals | Nausea, dizziness, sedation, constipation; seizures, serotonin syndrome, respiratory depression | Uncontrolled epilepsy, MAO inhibitors or intake within last 14 days, acute intoxication with central depressants. Caution with serotonergic medications | Moderate to severe pain when indicated | Primarily nociceptive; not first-line for neuropathic pain |
| Tilidine/Naloxone | Valoron N; Tilidin-ratiopharm plus; Tilidin AL comp. | Drops, sustained-release tablets | Sustained-release e.g. 50/4, 100/8, 150/12 or 200/16 mg | In opioid-naive adults e.g. 50/4 mg sustained-release p.o. every 12 hours; titrate individually | With respect to tilidine usually 100–600 mg/day, in sustained-release formulations in two doses; maximum 600 mg tilidine/day | Nausea, dizziness, fatigue, sweating; dependence and respiratory depression especially in risky constellations | Particular caution in severe liver insufficiency and with concomitant central depressants. Naloxone does not prevent all opioid risks when used correctly | Stronger pain when an opioid treatment is justified | Predominantly nociceptive |
| Morphine | MSI Mundipharma; MST Mundipharma; Oramorph | Injection solution, oral solution, immediate- and sustained-release formulations | For example 10 mg/ml as injection; sustained-release tablets 10/30/60/100/200 mg; other strengths available | Acute e.g. 1–2 mg slowly i.v., titrate according to effect under monitoring. Immediate-release p.o. in opioid-naive adults often 5–10 mg, adjusted individually | No general fixed daily maximum; limited by effect, side effects and organ function | Respiratory depression, sedation, nausea, constipation, urinary retention, hypotension | Relevant respiratory depression, paralytic ileus; in renal insufficiency risk of metabolite accumulation. Sustained-release forms not for rapid acute titration | Severe fracture, postoperative and cancer pain | Primarily severe nociceptive pain |
| Oxycodone | Oxygesic; Oxycodon-ratiopharm; Oxycodon HEXAL | Immediate-release capsules/tablets, sustained-release tablets; other forms product-dependent | Immediate-release e.g. 5/10/20 mg; sustained-release e.g. 5–80 mg | Immediate-release in opioid-naive adults often 5 mg p.o. every 6 hours; sustained-release often 5–10 mg every 12 hours, depending on risk profile | No general fixed daily maximum; titrate individually | Respiratory depression, sedation, nausea, constipation, itching | Relevant respiratory depression, paralytic ileus; dose adjustment in organ dysfunction. Consider CYP3A4 interactions; do not chew sustained-release tablets | Severe postoperative, cancer and other appropriate severe pain | Predominantly nociceptive |
| Hydromorphone | Palladon; Hydromorphon-ratiopharm; Hydromorphon-dura | Immediate-release capsules, sustained-release formulations, injection solution | Immediate-release: 1.3/2.6 mg; sustained-release e.g. 4/8/16/24 mg | Immediate-release often initially 1.3 mg p.o. every 4 hours; in selected patients 2.6 mg. Sustained-release dosing set separately | No general fixed daily maximum; titrate individually | Respiratory depression, sedation, constipation, nausea | Relevant respiratory depression, paralytic ileus; caution in renal and hepatic insufficiency. Opioid conversions only with appropriate equivalence calculation | Severe pain, especially in cancer and palliative situations; other appropriate indications | Predominantly nociceptive |
| Fentanyl, transdermal | Durogesic SMAT; Fentanyl-ratiopharm; Matrifen — partly international products | Transdermal patches | For example 12/25/50/75/100 µg/h | Choose patch strength based on an existing opioid therapy and an appropriate conversion; change usually every 72 hours | No blanket daily maximum; continuous delivery in µg/h, not as usual single dose in mg | Respiratory depression, sedation, constipation, nausea; overdose with increased uptake | Not for acute pain or routine initiation in opioid-naive patients. Do not use heating pads or hot water bottles on the patch; consider fever and CYP3A4 interactions | Severe chronic pain with an appropriate, preferably stable opioid requirement | Predominantly chronic-nociceptive |
| Buprenorphine, transdermal | Norspan; Transtec PRO; Buprenorphin-ratiopharm | Transdermal patches | 7-day systems e.g. 5/10/20/30/40 µg/h; other systems 35/52.5/70 µg/h | In suitable opioid-naive patients a 7-day patch with 5 µg/h can be started. Other systems require their own scheme | With the Norspan scheme up to 40 µg/h; Transtec-PRO systems have different limits. Systems are not interchangeable | Nausea, constipation, dizziness, sedation, skin reactions; respiratory depression | Not for rapid treatment of acute pain. Avoid heat; caution with sedatives. Do not cut patches | Appropriate chronic pain; depending on system moderate to severe pain | Predominantly chronic-nociceptive |
| Active ingredient | Three brand names | Forms | Typical strengths | Single dose and administration | Daily dose / Maximum | Important side effects | Contraindications and precautions | Indications | Type of pain |
|---|---|---|---|---|---|---|---|---|---|
| Pregabalin | Lyrica; Pregabalin-ratiopharm; PregabaHEXAL | Capsules, partly tablets, oral solution | Capsules: 25–300 mg; solution: 20 mg/ml | With normal renal function start e.g. 75 mg p.o. twice daily; in frail patients individually lower | 150–600 mg/day in two or three doses; maximum 600 mg/day with normal renal function | Dizziness, fatigue, edema, weight gain; respiratory depression, dependence and withdrawal | Hypersensitivity; dose adjust in renal insufficiency. Caution with opioids and other sedatives; taper off when stopping | Painful diabetic polyneuropathy, postherpetic neuralgia, other peripheral or central neuropathic pains | Neuropathic |
| Gabapentin | Neurontin; Gabapentin-ratiopharm; Gabapentin HEXAL | Capsules, tablets | Capsules: 100/300/400 mg; tablets: 600/800 mg | Possible scheme: Day 1 300 mg once, Day 2 300 mg twice, Day 3 300 mg three times p.o.; slower with increased risk | Often 900–3,600 mg/day in three doses; maximum 3,600 mg/day with normal renal function | Fatigue, dizziness, ataxia, edema; respiratory depression in risk constellations, dependence and withdrawal | Hypersensitivity; renal dosing. Caution with opioids and other sedatives; do not stop abruptly | Painful diabetic polyneuropathy, postherpetic neuralgia, other peripheral neuropathic pains | Neuropathic |
| Active ingredient | Three brand names | Forms | Typical strengths | Single dose and administration | Daily dose / Maximum | Important side effects | Contraindications and precautions | Indications | Type of pain |
|---|---|---|---|---|---|---|---|---|---|
| Duloxetine — SNRI | Cymbalta; Duloxetin-ratiopharm; Duloxetin Viatris | Gastro-resistant capsules | 30/60 mg | For painful diabetic neuropathy usually 60 mg p.o. once daily | Usually 60 mg/day; in selected patients up to 120 mg/day; higher doses do not reliably give more benefit | Nausea, sweating, dry mouth, dizziness, blood pressure increase; serotonin syndrome, discontinuation symptoms | Relevant liver disease, creatinine clearance <30 ml/min, uncontrolled hypertension at start; certain MAO inhibitors and strong CYP1A2 inhibitors | Painful diabetic polyneuropathy; fibromyalgia in Germany possibly off-label | Neuropathic; in fibromyalgia nociplastic |
| Amitriptyline — tricyclic antidepressant | Amineurin; Saroten; Amitriptylin-neuraxpharm | Tablets, partly sustained-release, oral solution | For example 10/25/50 mg; salt and active substance indications differ between products | Start usually 10–25 mg p.o. at night, then slow increase | For neuropathic pain usually 25–75 mg/day. Higher doses only after special assessment; no blanket maximum for all indications | Fatigue, dry mouth, constipation, urinary retention, weight gain, orthostatic hypotension, arrhythmias | Recent myocardial infarction, relevant rhythm/conduction disorders, certain MAO inhibitors; caution with narrow-angle glaucoma and urinary retention | Neuropathic pain; prophylaxis of chronic tension-type headache and migraine; fibromyalgia possibly off-label | Neuropathic; selected chronic or nociplastic pains |
| Active ingredient | Three brand names | Forms | Typical strengths | Single dose and administration | Daily dose / Maximum | Important side effects | Contraindications and precautions | Indications | Type of pain |
|---|---|---|---|---|---|---|---|---|---|
| Lidocaine | Versatis; Xylocain; Lidocain B. Braun — different forms | Active-ingredient patches; other products as injection, gel or spray | Versatis: 5%, 700 mg/patch; injections e.g. 1% or 2% | For postherpetic neuralgia 1–3 patches cutaneously, depending on area | Maximum 3 patches simultaneously, max 12 hours/24 hours, then at least 12 hours break. This limit applies only to the patch | Local skin reactions; with excessive systemic uptake neurological and cardiac toxicity | Allergy to amide local anesthetics; patch only on intact, healed skin. Injection doses determine separately by technique, body weight and product | Patches: localized postherpetic neuralgia; other forms: local or regional anesthesia | Localized neuropathic; in anesthesia blockade of pain conduction |
| Active ingredient | Three brand names | Forms | Typical strengths | Single dose and administration | Daily dose / Maximum | Important side effects | Contraindications and precautions | Indications | Type of pain |
|---|---|---|---|---|---|---|---|---|---|
| Celecoxib | Celebrex; Celecoxib-ratiopharm; Celecoxib TAD | Hard capsules | 100/200 mg | In osteoarthritis often 200 mg p.o. once daily or 100 mg twice daily; in other approved indications possibly higher | Usually 200–400 mg/day, maximum 400 mg/day | Abdominal complaints, edema, blood pressure increase, renal dysfunction; thrombotic events | Known coronary artery disease, peripheral arterial disease or cerebrovascular disease, heart failure NYHA II–IV, active ulcers, severe renal/hepatic insufficiency; sulfonamide hypersensitivity; pregnancy | Osteoarthritis, rheumatoid arthritis, ankylosing spondylitis | Somatic-nociceptive, particularly inflammatory |
| Etoricoxib | Arcoxia; Etoricoxib-ratiopharm; Etoriax | Film-coated tablets | 30/60/90/120 mg | Once daily p.o.: osteoarthritis usually 30 mg; rheumatoid arthritis or ankylosing spondylitis usually 60 mg; acute gout attack 120 mg | Indication-dependent: osteoarthritis up to 60 mg/day; RA/spondylitis up to 90 mg/day; gout 120 mg/day max 8 days; postoperative dental pain 90 mg/day max 3 days | Blood pressure increase, edema, renal dysfunction, gastrointestinal complaints; thrombotic events | Among others inadequately controlled blood pressure over 140/90 mmHg, known vascular disease, heart failure NYHA II–IV, active ulcers, severe organ insufficiency; pregnancy | Osteoarthritis, rheumatoid arthritis, ankylosing spondylitis, acute gout attack, short-term postoperative dental pain | Somatic-nociceptive, often inflammatory |
Combination analgesics
| Active ingredients | Trade name – example | Form and strength | Single dose | Repeat and daily maximum | Important side effects | Contraindications and precautions |
|---|---|---|---|---|---|---|
| ASA + paracetamol + caffeine | Thomapyrin Intensiv | Per tablet 250 mg ASA + 250 mg paracetamol + 50 mg caffeine | For migraine usually 2 tablets p.o. | If needed after 4–8 hours; maximum 6 tablets/24 hours | Stomach complaints, bleeding, restlessness, palpitations and sleep disturbances | Observe the contraindications of ASA and paracetamol. No additional uncontrolled intake of the same active substances. Caffeine can worsen anxiety, palpitations and sleep disturbances. |