Pharmacotherapeutic management of trigeminal neuropathic pain: an update

ABSTRACT

Introduction

Guidelines recommend a number of pharmacotherapeutic options used as monotherapy or in combination with others for treating the pain of trigeminal neuropathy.

Areas Covered

The authors examine the pharmacotherapeutic options for treating trigeminal neuralgia and supporting evidence in the literature. Guidelines reported the most effective treatment for trigeminal neuropathy, in particular trigeminal neuralgia, appears to be carbamazepine or oxcabazepine, but side effects can be treatment limiting. Lamotrigine and gabapentin are also recommended in guidance. In real-world clinical practice, baclofen, cannabinoids, eslicarbazepine, levetiracetam, brivaracetam, lidocaine, misoprostol, opioids, phenytoin, fosphenytoin, pimozide, sodium valproate, sumatriptan, tizanidine, tocainide, tricyclic antidepressants, and vixotrigine are sometimes used, either as monotherapy or in combination. The relatively small patient population has limited the number of large-scale studies and there is limited evidence on which to base prescribing choices.

Expert opinion

While there is no optimal pharmacotherapy for treating trigeminal neuropathy, advancements in our understanding of the underlying mechanisms of this condition and drug development indicate promise for NaV inhibitors, despite the fact that not all patients respond to them and they may have potentially treatment-limiting side effects. Nevertheless, better understanding of NaV channels may be important avenues for future drug development for trigeminal neuropathy.

KEYWORDS:

• Pharmacotherapeutic management
• trigeminal neuropathy
• monotherapy
• combination therapy
• sodium channel blockers

Article highlights

• Trigeminal neuropathy, in particular trigeminal neuralgia, is associated with vascular compression of the trigeminal nerve root near the pons of the brainstem and this can cause morphological changes to the nerve root itself.

• Guidelines for treating trigeminal neuropathy emphasize pharmacotherapy first over neurosurgery and the front-line pharmacologic agents, carbamazepine and oxcarbazepine, are very effective but associated with potentially treatment-limiting adverse events

• Pharmacologic treatment of trigeminal neuropathy may involve combination approaches such as carbamazepine and pregabalin or carbamazepine and baclofen but there are only limited studies.

• In real-world clinical practice other agents besides those in the guidelines are used such as baclofen, opioids, sodium-channel blockers, misoprostol, pimozide, sumatriptan, tizanidine, tricyclic antidepressants, and others.

• Vixotrigine, a voltage-gated sodium channel antagonist, and novel selective voltage-gated sodium channel blockers show promise

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This manuscript was not funded.