Raeder Paratrigeminal Syndrome Medication

Updated: Aug 15, 2018
  • Author: Steven H Schechter, MD; Chief Editor: Robert A Egan, MD  more...
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Medication

Medication Summary

For the management of pain associated with Raeder paratrigeminal syndrome, the antispasticity medication baclofen or anticonvulsants such as gabapentin, pregabalin, carbamazepine, and topiramate may be effective. Anti-inflammatory agents can also be effective, and, at times, narcotic analgesics may be necessary.

The efficacy of tricyclic antidepressants (TCAs) has been demonstrated in controlled trials for idiopathic facial pain and appears to be independent of the antidepressant effect. Steroids may also be effective in some patients.

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Anticonvulsants, Other

Class Summary

Many agents in this class are effective in the treatment of chronic pain syndromes.

Topiramate

Topiramate is indicated for migraine headache prophylaxis and for use as an anticonvulsant. Its precise mechanism of action is unknown, but the following properties may contribute to its efficacy:

• Blocks voltage-dependent sodium channels - According to electrophysiologic and biochemical evidence

• Augments the activity of the neurotransmitter GABA at some GABA-A receptor subtypes

• Antagonizes the AMPA (alpha-amino-3-hydroxy-5-methyl-4-isoxazole propionic acid)/kainate subtype of the glutamate receptor

• Inhibits the carbonic anhydrase enzyme - Particularly isozymes II and IV

Gabapentin (Neurontin)

Gabapentin is effective in treating neuralgia and chronic pain, likely due to its immunomodulatory effect. Gabapentin is structurally related to gamma-aminobutyric acid (GABA) but does not interact with GABA receptors. It is not converted metabolically into GABA or a GABA agonist and is not an inhibitor of GABA uptake or degradation. Gabapentin does not exhibit an affinity for other common receptor sites.

Carbamazepine (Tegretol, Carbatrol, Epitol)

Carbamazepine is the drug of choice that may reduce polysynaptic responses and block posttetanic potentiation. This agent may depress the activity of the nucleus ventralis of the thalamus or decrease synaptic transmission or summation of temporal stimulation, leading to neural discharge by limiting the influx of sodium ions across the cell membrane or other unknown mechanisms. The target blood serum concentration is 4-12mg/L.

Pregabalin (Lyrica)

Pregabalin is similar to gabapentin but has a faster clinical effect without the slow titration. It reduces the calcium-dependent release of several neurotransmitters, possibly by modulation of calcium channel function. Twice-daily dosing may improve compliance.

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Analgesics, Other

Class Summary

Pain control is essential to quality patient care. Analgesics ensure patient comfort, promote pulmonary toilet, and have sedating properties, which are beneficial to patients who have sustained trauma or injuries.

Naproxen (Naprosyn, Naprelan, Aleve, Anaprox)

Naproxen is well-absorbed orally and is not usually associated with rebound headaches. It is used for the relief of mild to moderate pain. Naproxen inhibits inflammatory reactions and pain by decreasing the activity of cyclo-oxygenase, which is responsible for prostaglandin synthesis. It is inexpensive and can be purchased over the counter.

Ibuprofen (Motrin, Advil, NeoProfen, Ultraprin)

Ibuprofen inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis. It is used to provide relief of pain.

Indomethacin (Indocin)

Indomethacin is thought to be the most effective NSAID for the treatment of pain, although no scientific evidence supports this claim. It is used for relief of mild to moderate pain; it inhibits inflammatory reactions and pain by decreasing the activity of COX, which results in a decrease of prostaglandin synthesis.

Diclofenac (Voltaren, Cataflam XR, Zipsor, Cambia)

Diclofenac inhibits prostaglandin synthesis by decreasing COX activity, which, in turn, decreases formation of prostaglandin precursors.

Ketoprofen

Ketoprofen is used for relief of mild to moderate pain and inflammation. Small dosages are indicated initially in small patients, elderly patients, and patients with renal or liver disease. Doses higher than 75 mg do not increase the therapeutic effects. Administer high doses with caution, and closely observe the patient's response.

Acetaminophen and codeine (Tylenol #3)

This combination is indicated for the treatment of mild to moderate pain.

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Corticosteroids

Class Summary

Corticosteroids have anti-inflammatory properties and cause profound and varied metabolic effects. In addition, these agents modify the body's immune response to diverse stimuli.

Prednisone

Corticosteroids are the most commonly used and most versatile immunosuppressants. Corticosteroids have many complex actions and a broad range of immunosuppressive and anti-inflammatory effects. They induce lymphocytopenia, interfere with the production and function of numerous lymphokines, and disrupt intercellular communication among leukocytes. Use the lowest effective dose, weighing benefits against risks in each patient.

Methylprednisolone (A-Methapred, Solu-Medrol, Depo-Medrol)

Methylprednisolone is available in intravenous (IV)/intramuscular (IM) or oral (PO) form. Methylprednisolone may decrease inflammation by reversing increased capillary permeability and suppressing polymorphonuclear (PMN) leukocyte activity.

Prednisolone (Pediapred, Prelone, Orapred)

Prednisolone may decrease inflammation by reversing increased capillary permeability and suppressing polymorphonuclear (PMN) leukocyte activity. It is a commonly used oral agent.

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Antidepressants, TCAs

Class Summary

These are a complex group of drugs that have central and peripheral anticholinergic effects, as well as sedative effects. TCAs have central effects on pain transmission. They block the active reuptake of norepinephrine and serotonin.

Amitriptyline (Elavil)

Amitriptyline can be used with a slow titration schedule. This agent can be useful if a mild sedative effect is desired. It can be dosed at night.

Clomipramine (Anafranil)

Clomipramine is a dibenzazepine compound belonging to the family of tricyclic antidepressants. The drug inhibits the membrane pump mechanism responsible for the uptake of norepinephrine and serotonin in adrenergic and serotonergic neurons.

Clomipramine affects serotonin uptake while it affects norepinephrine uptake when converted into its metabolite desmethylclomipramine. It is believed that these actions are responsible for its antidepressant activity.

Doxepin (Silenor)

Doxepin increases the concentration of serotonin and norepinephrine in the CNS by inhibiting their reuptake by the presynaptic neuronal membrane. It inhibits histamine and acetylcholine activity and has proven useful in the treatment of various forms of depression associated with chronic pain.

Nortriptyline (Pamelor)

Nortriptyline has demonstrated effectiveness in the treatment of chronic pain.

Desipramine (Norpramin)

This is the original TCA used for depression and has been shown to help treat chronic pain. These agents have been suggested to act by inhibiting reuptake of noradrenaline at synapses in central descending pain-modulating pathways located in the brainstem and spinal cord.

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Skeletal Muscle Relaxants

Class Summary

These drugs are effective in some patients for pain management.

Baclofen (Lioresal)

Baclofen is a centrally acting muscle relaxant; its precise mechanism of action is unknown. It is a GABA analog and may exert its effects by stimulation of GABA-beta receptors. Baclofen inhibits monosynaptic and polysynaptic reflexes at the spinal level by hyperpolarization of afferent terminals.

Cyclobenzaprine (Flexeril, Fexmid, Amrix)

Cyclobenzaprine acts centrally and reduces motor activity of tonic somatic origins, influencing alpha and gamma motor neurons. It is structurally related to the tricyclic antidepressants.

Skeletal muscle relaxants have modest, short-term benefit as adjunctive therapy for nociceptive pain associated with muscle strains and, used intermittently, for diffuse and certain regional chronic pain syndromes. Long-term improvement over placebo has not been established.

Cyclobenzaprine often produces a "hangover" effect, which can be minimized by taking the nighttime dose 2-3 hours before going to sleep.

Carisoprodol (Soma)

Carisoprodol is a short-acting medication that may have depressant effects at the spinal cord level.

Skeletal muscle relaxants have modest short-term benefit as adjunctive therapy for nociceptive pain associated with muscle strains and, used intermittently, for diffuse and certain regional chronic pain syndromes. Long-term improvement over placebo has not been established.

Tizanidine (Zanaflex)

Tizanidine is a centrally acting muscle relaxant that is metabolized in the liver and excreted in the urine and feces. It is used in patients with predominantly upper motor neuron involvement. It is not a DEA-controlled substance.

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