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Trigeminal Neuralgia: Treatment & Medication
Updated: Apr 16, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Emergency Department Care
Care in the ED is generally limited to correct identification of trigeminal neuralgia (TN), consideration of alternative diagnosis, pain relief, and coordination of follow-up care.
- Because of the time-limited character of pain with typical trigeminal neuralgia, patients often do not present to the ED for pain medication.
- In some patients, the typically episodic pain becomes constant or so frequent as to be debilitating.
- Infusion of phenytoin is reportedly successful in interrupting such episodes, but the value of this therapy is anecdotal.
- Coordinate therapy for refractory pain of trigeminal neuralgia with the primary care physician or consultants.
Consultations
Patients with a typical history and normal physical examination may be referred to their primary care physician for further care. Neurologic or neurosurgical consultations may be helpful, particularly if atypical features are present.
- Referral to a neurologist may be helpful if the diagnosis is in doubt.
- Referral to a neurosurgeon may be indicated for patients whose conditions prove refractory to medical treatment. Percutaneous radiofrequency ablation of a portion of the trigeminal ganglion is commonly performed, as are anesthetic blocks of the trigeminal ganglion. Less commonly performed is decompression of the region of trigeminal root entry of impinging vascular structures.
- Comprehensive pain center follow-up care may be helpful.
Medication
The goal of pharmacologic therapy is to reduce pain. Carbamazepine is regarded by most as the medical treatment of choice. Some advocate a trial of baclofen since it has fewer adverse effects. The synergistic combination of carbamazepine and baclofen may provide relief from episodic pain though convincing clinical evidence is weak at best.
Other anticonvulsants including phenytoin, oxcarbazepine, clonazepam, lamotrigine, valproic acid, and gabapentin are reportedly beneficial in some patients; however, controlled trials have not been performed. The American Academy of Neurology published a practice parameter that concluded that carbamazepine is effective in controlling pain of patients with classic trigeminal neuralgia, and that oxcarbazepine is probably effective. Baclofen, lamotrigine, and pimozide were rated as possibly effective. The practice parameter stated that there was insufficient evidence to support or refute efficacy of clonazepam, gabapentin, phenytoin, tizanidine, topical capsaicin, or valproate for pain control in patients with classic trigeminal neuralgia.1 The writing group was unable to find sufficient evidence to support or refute the use of intravenous medications in acute exacerbations of trigeminal neuralgia.
Anticonvulsants
These agents may help control paroxysmal pain by limiting the aberrant transmission of nerve impulses.
Carbamazepine (Tegretol)
Anticonvulsant effective in the treatment of psychomotor and grand mal seizure. DOC for TN. May reduce polysynaptic responses and block post-tetanic potentiation.
Once patient responds to therapy, attempt to reduce dose to minimum effective level, or attempt to discontinue at 3-mo intervals.
Adult
100 mg PO bid on day 1; increase by up to 200 mg/d using 100-mg increments q12h prn; not to exceed 1200 mg/d
Pediatric
<12 years: Not established
>12 years: Administer as in adults
Serum levels may increase significantly within 30 d of danazol coadministration (avoid whenever possible); do not coadminister with MAOIs; cimetidine may increase toxicity, especially if taken in first 4 wk of therapy; carbamazepine may decrease primidone and phenobarbital levels (their coadministration may increase carbamazepine levels)
Documented hypersensitivity; history of bone marrow depression; administration of MAOIs within last 14 d
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Do not use to relieve minor aches or pains; caution with increased intraocular pressure; obtain CBCs and serum-iron baseline prior to treatment, during first 2 mo, and yearly or every other year thereafter; can cause drowsiness, dizziness, and blurred vision; caution while driving or performing other tasks that require alertness
Skeletal muscle relaxants
These agents are useful in the treatment of TN, although not FDA-approved for this indication. They have CNS depressant properties as indicated by the production of sedation with somnolence, ataxia, and respiratory and cardiovascular depression.
Baclofen (Lioresal)
Most often used after therapy with carbamazepine has been initiated. Effects may be synergistic with those of carbamazepine. May induce hyperpolarization of afferent terminals and may inhibit both monosynaptic and polysynaptic reflexes at spinal level. As a structural analog of the inhibitory neurotransmitter GABA, may stimulate GABA-B receptor subtype.
Adult
5 mg/d PO tid on days 1-3; followed by 10 mg/d PO tid on days 4-6; followed by 15 mg/d PO tid on days 7-9; followed by 20 mg/d PO tid on days 10-12; additional increases may be necessary; not to exceed 80 mg/d divided qid
Pediatric
Not established
Opiate analgesics, benzodiazepines, and hypertensive agents increase effects; similarly, alcohol, tricyclic antidepressants, guanabenz, MAOIs, and clindamycin may increase effects
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in patients with history of autonomic dysreflexia and when spasticity is used to obtain increased function; autonomic dysreflexia can result from withdrawal of this medication
More on Trigeminal Neuralgia |
| Overview: Trigeminal Neuralgia |
| Differential Diagnoses & Workup: Trigeminal Neuralgia |
 Treatment & Medication: Trigeminal Neuralgia |
| Follow-up: Trigeminal Neuralgia |
| Multimedia: Trigeminal Neuralgia |
| References |
| Further Reading |
| « Previous Page | Next Page » |
References
Gronseth G, Cruccu G, Alksne J, Argoff C, Brainin M, Burchiel K, et al. Practice parameter: the diagnostic evaluation and treatment of trigeminal neuralgia (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology and the European Federation of Neurological Societies. Neurology. Oct 7 2008;71(15):1183-90. [Medline].
Bennetto L, Patel NK, Fuller G. Trigeminal neuralgia and its management. BMJ. Jan 27 2007;334(7586):201-5. [Medline].
Cheshire WP Jr. The shocking tooth about trigeminal neuralgia. N Engl J Med. Jun 29 2000;342(26):2003. [Medline].
Chole R, Patil R, Degwekar SS, Bhowate RR. Drug treatment of trigeminal neuralgia: a systematic review of the literature. J Oral Maxillofac Surg. Jan 2007;65(1):40-5. [Medline].
Kubitz PK, Wijdicks EF, Bolton CF. Tic douloureux or "tic dentaire". Neurology. Jan 27 2004;62(2):333. [Medline].
Liu JK, Apfelbaum RI. Treatment of trigeminal neuralgia. Neurosurg Clin N Am. Jul 2004;15(3):319-34. [Medline].
Rasche D, Kress B, Schwark C, Wirtz CR, Unterberg A, Tronnier VM. Treatment of trigeminal neuralgia associated with multiple sclerosis: case report. Neurology. Nov 9 2004;63(9):1714-5. [Medline].
Zvartau-Hind M, Din MU, Gilani A, Lisak RP, Khan OA. Topiramate relieves refractory trigeminal neuralgia in MS patients. Neurology. Nov 28 2000;55(10):1587-8. [Medline].
Further Reading
Clinical guidelines
Practice parameter: the diagnostic evaluation and treatment of trigeminal neuralgia (an evidence-based review). Report of the Quality Standards Subcommittee of the American Academy of Neurology and the European Federation of Neurological Societies. Gronseth G, Cruccu G, Alksne J, Argoff C, Brainin M, Burchiel K, Nurmikko T, Zakrzewska JM. Practice Parameter: The diagnostic evaluation and treatment of trigeminal neuralgia (an evidence-based review). Report of the Quality Standards Subcommittee of the American Academy of Neurology and the European Federation of Neurological Societies. Neurology 2008 Oct 7;71(15):1183-90.
Keywords
trigeminal neuralgia, symptoms, treatment, causes, TN, tic douloureux, pain syndrome, idiopathic TN, idiopathic trigeminal neuralgia, secondary trigeminal neuralgia, secondary TN, facial spasm, tic, abnormal vessels, aneurysms, tumors, chronic meningeal inflammation, multiple sclerosis, vascular anomalies
