Treatment Options for Trigeminal Neuralgia

Drug Therapy for Trigeminal Neuralgia

The goal of drug therapy is to provide facial pain relief with minimal drug-related side-effects. The majority of patients with trigeminal neuralgia achieve pain relief with drug therapy. Many patients are pain-free for a number of years after the initiation of drug therapy. Drug therapy should bring rapid relief to patients suffering from trigeminal neuralgia. If the patient does not experience satisfactory relief, the diagnosis of TN may have to be reexamined.

Over time, most patients with TN require increasing doses of medications and many are placed on more than one medication in the hope of controlling their facial pain. For patients in whom the pain is intractable and does not respond to medication, surgical intervention may be recommended.

Commonly used medications for the medical treatment of TN include:

• Anticonvulsants
• Muscle relaxants
• Other medications

Anticonvulsants

Carbamazepine

Carbamazepine (Tegretol) is the gold standard of TN treatment and provides relief for 70-90% of the patients. In fact, carbamazepine is so effective initially that the lack of response often calls into question the accuracy of a diagnosis of trigeminal neuralgia. Approximately 20% of patients do not respond or cannot tolerate the drug at levels sufficient to have an effect on the pain. There is also a sustained release form of this drug available.

Adverse reactions may include:

• Nausea
• Dizziness
• Nystagmus (rhythmic oscillation of the eyeball)
• Drowsiness
• Aplastic anemia
• Agranulocytosis (an acute condition resulting in a reduction of white blood cells called granulocytes in the blood)

It is recommended that patients taking carbamazepine be monitored monthly or bimonthly for:

• CBC (complete blood count)
• Blood urea nitrogen
• Creatinine
• Liver function

Patients need to report any sign of fever, infection, sore throat, bleeding or signs of bone marrow suppression. Carbamazepine interacts with many drugs so the patient must be carefully monitored regarding all medications.

Oxcarbazepine

Oxcarbazepine (Trileptal) is similar to carbamazepine in its effectiveness but seems to be better tolerated. In some European countries, it is given as the first line of treatment for TN. In the U.S., oxcarbazepine is often given to patients who cannot tolerate carbamazepine or who no longer achieve pain relief.

Adverse reactions may include:

• Headache
• Dizziness
• Drowsiness
• Skin rash

Gabapentin

Gabapentin (Neurontin) is one of the newer anticonvulsant. It is very effective for trigeminal neuralgia and has fewer side effects than other anticonvulsants. It may be used alone or combined with other drugs. Gabapentin is more expensive than other anticonvulsants.

Adverse reactions may include:

• Drowsiness
• Headache
• Dizziness
• Nausea
• Vomiting

Phenytoin

Phenytoin (Dilantin) is one of the oldest drugs used for trigeminal neuralgia and is effective for 20-25% of patients. If there is no pain relief after approximately 3 weeks, doctors may discontinue the drug since increasing the doses above a certain point leads to toxicity. This also may be given alone or in combination with another drug.

Adverse reactions may include:

• Dizziness
• Sedation
• Impaired attention or memory
• Double vision

Lamotrigine (Lamictal)

Adverse reactions may include:

• Headache
• Dizziness
• Nausea
• Insomnia

Muscle Relaxants

Baclofen

Baclofen (Lioresal) is an antispastic drug that is sometimes used alone but is usually prescribed in combination with an anticonvulsant.

Adverse effects may include:

• Confusion
• Depression
• Drowsiness
• Psychosis

Other Medications:

Other drugs that may be used for the treatment of TN include:

• Divalproex (Depakote)
• Clonazapam (Ativan)
• Capsaicin (Zostrix) - This is a topical analgesic cream which when applied to a painful region reduces pain. This is not a standard treatment but some patients with TN have reported relief using this substance.