Introduction

Have you ever experienced an itchy sensation, sometimes accompanied by a burning or painful feeling, on one side of your upper back near the spine, which has lasted for months? It could very well be a condition known as Notalgia Parethetica which is a long-term nerve condition that mostly affects older women.

There are different forms of treatment. Some are local, like capsaicin cream, topical corticosteroids, and anaesthetics. Others are oral medications like antihistamines, gabapentin, and pregabalin.¹

This article will help you understand how these treatments work, when they are used, and what you should know about their effectiveness and possible side effects. 

What is Notalgia Paresthetica?

Notalgia paresthetica is a long-term nerve condition that primarily affects older women. It usually shows up on one side of the upper back, near where the shoulder blade meets the spine. The itching and discomfort can persist for months, sometimes even up to a year. Although rashes do not show up at first, they may develop later if the area is scratched repeatedly.

What are the Causes of Notalgia Parethetica?

The exact cause of notalgia paresthetica is not fully understood. There are different possible causes, and many scientists believe it has to do with an irritation or damage to the thoracic nerves, particularly nerves 2 to 6.

What we do know for sure is that it tends to happen when there are degenerative changes in the thoracic spine, putting pressure on the nerves. This pressure leads to symptoms like itching, pain, and sometimes even a burning sensation.

The causes generally fall into a few categories:¹

• Physical Causes—Muscle spasms or tension compress sensitive nerves, which trigger abnormal signals, making you feel these symptoms
• Anatomical Issues — Some scientists believe that the position of certain nerves, which are sensitive to histamine (a substance involved in itching), may contribute. These nerves pass through a type of muscle responsible for keeping the spine straight (multifidus spinae). The angle at which they pass through could irritate or compress the nerves, leading to these symptoms
• Other possible causes include genetics, where a family history might increase your chances of having the condition. Metabolic issues, like type 2 diabetes, and infections, such as shingles, may also play a role

How Nerve Damage Causes the Itching

When nerves get irritated or injured, they release certain substances that can make the itching worse. These substances, like Calcitonin Gene-Related Peptide (CGRP), activate special channels in the skin that are sensitive to things like heat and irritation (for example, the same channels that respond to pepper and wasabi).

Over time, the constant signals from the irritated nerves can make the spinal cord more sensitive too, meaning it takes even less stimulation to cause itching. This is why notalgia paresthetica often shows up as a stubborn itch on one side of the upper back. If it goes on for long enough, scratching can cause the skin to become darker or rougher.²

Treatment options for Notalgia Parethetica 

Treatment for notalgia paresthetica generally falls into two categories: local treatments and oral treatments.

Local treatments are usually the first step, especially for milder cases. They include things like capsaicin creams, topical corticosteroids, anaesthetics, and coolants. These work by calming the irritated nerves in the skin and helping to reduce the itching and discomfort. However, while they can provide temporary relief, they often do not address the deeper nerve irritation that is causing the symptoms.

Other options like Botox A injections and transcutaneous electrical nerve stimulation (TENS) have also been used, but their effectiveness can differ from person to person.¹

Oral Treatments for Notalgia Parethetica 

Oral medications are considered when local treatments do not provide enough relief. The main options include:

Antihistamines 

Antihistamines are sometimes used in the treatment of notalgia paresthetica, but they do not directly target the root cause, as the condition is not primarily driven by the histamine pathway. Instead, notalgia paresthetica arises when your nerves are irritated or compressed.

However, histamine can still play a secondary role. Mechanical stimulation of the skin like scratching can trigger histamine release from mast cells.³ This may worsen the itching or create a cycle of scratching and irritation. By blocking histamine receptors (especially H1 and H4 receptors on C-fibres), antihistamines can reduce some of this secondary itching.

Their main benefit, especially with first-generation antihistamines, comes from their sedative effect, which helps reduce nighttime or unconscious scratching.¹

Some examples include:

Hydroxyzine 

This is a first-generation antihistamine, and it can make you drowsy. It also comes with side effects like dry mouth, dizziness, and blurred vision and may interact with other medications.

Diphenhydramine 

This is another first-generation antihistamine, which also makes you drowsy. It has the same side effects as other first-generation antihistamines, and older adults using them should be monitored carefully.

Cetirizine 

This is a second-generation antihistamine that is less likely to cause drowsiness, unlike the first generation. The side effects are generally milder, but it can still cause drowsiness in some people. 

Although these antihistamines may provide some benefit, they mainly help by reducing scratching, particularly during sudden episodes, nocturnal scratching, or when the patient is distracted, rather than addressing the underlying nerve issue itself.⁴

Gabapentin 

Gabapentin is often used when local treatments and antihistamines are not enough to control the symptoms of notalgia paresthetica. It is a medicine designed to resemble gamma-aminobutyric acid (GABA), a natural chemical in the brain that calms nerve activity.

Gabapentin is a medicine designed to resemble gamma-aminobutyric acid (GABA), a natural chemical in the brain that calms nerve activity. However, instead of acting directly on GABA receptors, gabapentin binds to a specific part of calcium channels in nerve cells. These calcium channels control the flow of calcium ions into the nerves. When excessive calcium enters, the nerve cells become overactive and release substances like glutamate, norepinephrine, and substance P, certain chemicals that can increase the feeling of itching, burning, or pain.

It works by calming overactive nerves, which are thought to be the main cause of the itching and discomfort in this condition. By binding to these channels, gabapentin reduces calcium entry, helping to calm the nerves and lessen the release of these irritating substances. Since itching and pain often share similar nerve pathways, stabilising nerve activity can relieve both sensations.⁵

How effective is it?

Gabapentin has been shown to work well in treating different types of chronic itching, especially when the itch comes from nerve problems rather than allergies.

Compared to antihistamines and some antidepressants, it often gives better relief for nerve-related itching.⁴

Some possible side effects include:

• Drowsiness
• Tiredness
• Swelling in the legs
• Blurred vision

There are also increasing concerns about its misuse.

Research has found that people prescribed gabapentin, particularly those aged 15 and older, had higher rates of suicidal behaviour, accidental overdose, serious injuries, and traffic accidents.

Therefore, while gabapentin can offer real relief for nerve-related itching, such as notalgia paresthetica, it should be used cautiously and under close medical supervision.

Pregabalin 

Pregabalin is often used when local treatments and antihistamines are not enough to control the symptoms of notalgia paresthetica.

It works in a similar way to gabapentin, as it is designed to mimic gamma-aminobutyric acid (GABA), a natural chemical in the brain that helps regulate nerve activity.⁴

However, pregabalin differs from gabapentin in that it binds more strongly to a specific part of calcium channels in nerve cells.

These calcium channels control the flow of calcium ions into the nerves. When too much calcium enters, it can cause the nerves to become overactive and release substances like glutamate, norepinephrine, and substance P, chemicals that can intensify itching, burning, or pain. By binding to these calcium channels, pregabalin reduces the excessive calcium flow, helping to calm the overactive nerves and limit the release of these irritating substances.

Because pregabalin has a higher affinity for calcium channels, it may work faster and more predictably than gabapentin. This can make it an option for people who do not get enough relief from gabapentin or who experience side effects with it.

How effective is it?

Pregabalin has been shown to be effective in treating various forms of neuropathic itching, especially when the itch is related to nerve problems.

Pregabalin also has similar side effects to gabapentin.

Risks and Considerations

Similar to gabapentin, pregabalin carries a risk of misuse, particularly when combined with other sedating drugs. However, the symptoms of misuse, including physical dependence and withdrawal, tend to be more pronounced with pregabalin. 

This increased potential for misuse and dependence makes it particularly important for pregabalin to be used under close medical supervision.

Therefore, while pregabalin can offer significant relief for nerve-related itching like that caused by notalgia paresthetica, careful monitoring is essential to ensure safe and effective use.

Summary 

In summary, notalgia paresthetica is a chronic nerve condition which can cause persistent itching on one side of the upper back. This condition mostly affects older women and is caused by irritation or compression of thoracic spinal nerves. Notalgia paresthetica often needs more than just local treatments to be managed well. Oral medications like pregabalin and gabapentin tend to be the most effective options. While they can bring real relief, they also come with side effects, so working with a healthcare provider is important to get the best results and keep symptoms under control.

FAQs

Can notalgia paresthetica go away on its own?

Not usually. The symptoms may come and go, but for many people, the itch tends to persist without treatment. Managing the condition often requires medical support.

Is it safe to take these medications long-term?

It can be, but it depends on the person. Medications like pregabalin and gabapentin can be used long-term under close medical supervision to monitor side effects and adjust doses if needed.

What if none of the medications work for me?

If you don't get enough relief, your doctor may explore other options. These could include adjusting the medication, trying different doses, combining treatments, or even considering procedures like nerve blocks.

Are there any natural remedies worth trying?

Some people find temporary relief with cooling lotions, capsaicin creams, or physical therapy. While they might not cure the condition, they can help ease the discomfort for some individuals.

How quickly can I expect relief after starting treatment?

It varies. Some people notice improvement within days to a few weeks, while for others, it can take longer. It’s important to give the treatment time and stay in touch with your doctor about your progress.