Trigeminal neuralgia

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Clinical Findings

  • Paroxysms of severe unilateral pain in trigeminal nerve distribution lasting only seconds
  • Normal neuro exam
  • No pain between paroxysms

Treatment

Phenytoin 250 mg IV to abort an acute attack

  • Relief lasts from four hours to three days
  •  Fosphenytoin seems to work similarly15

Carbamazepine

  • First-line agent with 75% success rate initially
  • Proposed Mechanism: Decreases the response of neurons to peripheral stimulation
  • Started at 100 mg one to two times per day
  • Increase by 100-200 mg every 3 days
  • Usual maintenance dose is 400-800 mg (rare > 1500 mg)
  • Pain relief occurs within several hours to days (94% within 48
    hours)
  • Target serum concentration is 24-43 μmol/L
    • If unsuccessful, phenytoin 200-400 mg/day is used in combination
  • Other agents: Baclofen, Clonazepam, Valproic acid, Lamotrigine, Gabapentin, Oxcarbazepine, Topiramate
  • Posterior fossa microvascular decompressive surgery
    • Approximately 50% of patients will require surgery 

Successful in 70% of patients16

Source

Tintinalli

J Pain Symptom Manage 2001; 21(6):506-510.

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