One of the most common chronic complications arising from diabetes is diabetic peripheral neuropathy. Depending on research statistics, approximately half of the people who have diabetes will suffer from diabetic peripheral neuropathy over time, which manifests as abnormal sensations in the distal extremities, and about 25%-50% of these patients have symptoms of neuralgia, called painful diabetic neuropathy. These patients often exhibit adverse emotional conditions, like anxiety or depression, which can reduce their quality of life. The pathogenesis of diabetic peripheral neuropathy is complex, and although persistent hyperglycemia plays a central role in the development of diabetic peripheral neuropathy, strict glycemic control does not eliminate the risk of diabetic peripheral neuropathy. This suggests the need to understand the role of the central nervous system in the development of diabetic peripheral neuropathy to modulate treatment regimens accordingly. Magnetic resonance imaging not only allows for the noninvasive detection of structural and functional alterations in the central nervous system, but also provides insight into the processing of abnormal information such as pain by the central nervous system, and most importantly, contributes to the development of more effective pain relief protocols. Therefore, this article will focus on the mechanisms and related imaging evidence of central alterations in diabetic peripheral neuropathy, especially in painful diabetic neuropathy.