Guidelines for the management of trigeminal neuralgia

Mun Seng Chong; Anish Bahra; Joanna M. Zakrzewska

doi:10.3949/ccjm.90a.22052

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TABLE 1

Key symptoms of trigeminal neuralgia and differential diagnosis

Key symptoms	Other possible symptoms	Differential diagnosis
Paroxysmal pain Sharp and shooting Lasts seconds to minutes Provoked by light touch	Burning, prickling, dull tender constant background pain	Trigeminal neuralgia with concomitant, continuous pain
Trigeminal nerve innervation area	Interparoxysmal pain	Temporomandibular disorder
Pain cannot be evoked between attacks (refractory period)	Autonomic symptoms^a	SUNCT and SUNA
Periods of remission or relapse	Sensory change^b	Painful trigeminal neuropathy
Abrupt onset	After eating	Dental, cracked tooth

↵a Some facial reddening and tearing, sometimes on both sides, may be seen during acute pain paroxysms. If more pronounced with strictly unilateral conjunctival reddening, eyelid droop, nasal blockage, then consider SUNCT and SUNA.
↵b During a relapse of trigeminal neuralgia and especially just after paroxysms of pain, there may be subtle transient unilateral sensory change in the area innervated by the trigeminal nerve. The presence of permanent sensory alterations and atypical features such as absent refractory period and no pain remission raise the possibility of trigeminal nerve damage and painful trigeminal neuropathy.
SUNA = short-lasting unilateral neuralgiform headache attacks with autonomic features; SUNCT = short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing

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TABLE 2

Classification of trigeminal neuralgia

Type	Subtypes
Classic trigeminal neuralgia (neurovascular compression present)	Purely paroxysmal Concomitant continuous pain
Secondary trigeminal neuralgia (underlying pathology present)	Attributed to multiple sclerosis Attributed to space-occupying lesion Atributed to other causes
Idiopathic trigeminal neuralgia (no underlying cause found)	Purely paroxysmal Concomitant continuous pain

Based on data from reference 4.

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TABLE 3

Evidence-based pharmacotherapy for trigeminal neuralgia

Drug	Dosage regimen	Usual dose range	Common side effects
First-line therapy
Carbamazepine^a	100 mg twice daily; double after 3 days to 200 mg twice daily; increase by 100–200 mg twice daily every 3 days, then 200 mg 4 times daily	800–1,200 mg daily	Sedation, dizziness, blurred vision, nausea, unsteady lethargy, double vision, headache May cause hyponatremia, skin rashes, pancytopenia Risk of osteoporosis with long-term use May reduce oral contraception efficacy

Oxcarbazepine^a	150 mg twice daily, double to 300 mg twice daily after 3 days; increase by 150–300 mg twice daily every 3 days, then 300 mg 4 times daily	1,200–1,800 mg daily	Drowsiness, dizziness, diplopia, confusion, nausea, abdominal pain, headache, depression, diarrhea High risk of hyponatremia Chronic use risks osteoporosis May reduce oral contraception efficacy

Second-line therapy
Lamotrigine	Start 25 mg a day for 7 days, then 25 mg twice daily for 7 days, then 50 mg twice daily for another week; subsequent dose increments of 50 mg every 7 days, up to 10 weeks	200 mg twice daily	Blurred vision, agitation, aggression, unsteadiness, dizziness, nausea, dry mouth, insomnia, joint pains Risk of skin rashes and Stevens-Johnson syndrome with rapid dose escalation Probably safe for pregnant women at a dose of 100 mg twice daily

Baclofen	5 mg 3 times daily for 3 days, then increase to 10 mg 3 times daily for 3 days; increase by 10 mg 3 times daily every 3 days until maximum dose	40–80 mg daily	Anxiety, depression, agitation, unsteadiness, headache, sedation, tremor, skin rash, blurred vision, dry mouth, abdominal pain, withdrawal symptoms if stopped too rapidly

Gabapentin	100 mg 3 times daily day 1, 200 mg 3 times daily day 2 and 300 mg 3 times daily day 3. Increase by 1-300 mg 3 times daily every 3 days to maximum dose; start 100 mg 3 times daily or 300 mg at bedtime; can increase dose up to 300 to 600 mg 3 daily	900–3,600 mg daily	Amnesia, confusion, dizziness, vertigo, drowsiness, depression, nausea, blurred vision, peripheral edema, constipation, abdominal bloating, weight gain

Pregabalin	25 mg twice daily; increase by 25–50 mg twice daily every 3 days	600 mg daily	Confusion, drowsiness, constipation, blurred vision, dizziness, nausea, peripheral edema, increased appetite, weight gain

↵a Carbamazepine and oxcarbazepine are available in liquid form. Dosage ranges vary due to lack of high-quality trials.

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TABLE 4

Treatments for acute episodes of trigeminal neuralgia based on a systematic review

Provider	Treatment
All clinicians (dentist, general practitioner, specialist)	Lidocaine 10-mg nasal spray, 2 sprays into nostril on affected side; can be used intraorally, but spit out after 1 minute 5% ointment to trigger area 2% 1:80,000 adrenaline local infiltration to nerve block trigger area
General practitioner, specialist	Sumatriptan 6 mg subcutaneous injection, followed by oral sumatriptan 50 mg twice daily for 1 week
Specialist only	Botulinum toxin type A injection, 3 mg in 1 mL
Specialist, inpatient basis	Intravenous Infusions Lidocaine 1.5 mg/kg over 1 hour, up to 5 mg/kg in a randomized clinical trial Phenytoin 10 mg/kg Fosphenytoin 15 mg/kg