Medication

The frontline treatment for any of the chronic facial pain conditions is medication.

Anticonvulsants

Upon diagnosis of a neuropathic facial pain syndrome like TN, a doctor is likely to prescribe an anticonvulsant, also commonly known as antiepileptic drugs or as antiseizure drugs. Drugs in this class have been successfully used to combat neuropathic pain since the 1950’s.

For episodic, sharp, stabbing and electric pain the most proven effective agents include carbamazepine (Tegretol) and oxcarbazepine (Trileptal), both of which are in the same AED class and operate through similar mechanisms. For constant, dull, aching, or burning pain, the most effective AED’s appear to be gabapentin (Neurontin) and pregabalin (Lyrica), both of which are in the same AED class and operate through similar mechanisms.

There are many other AED’s that can be tried as third- or fourth-line agents, and some patients can be helped by adding a non-AED, such as the antispasmodic drug baclofen (Lioresal), or even a tricyclic anti-depressent such as amitriptyline (Elavil).

Anticonvulsant drugs are occasionally used as tools to confirm a diagnosis. If a drug from this class provides relief where traditional pain medications have failed, that is considered diagnostic proof of neuropathic pain.

Traditional Pain Medications

Medications that are indicated for acute pain and the pain of traumatic injury are not considered by most physicians to be the first or best choices for treating neuropathic facial pain. However, as proven time and again by facial pain patients who cannot function without them, they do have an important place in the arsenal.

Opioids are helpful to many facial pain patients. Although they do not eliminate the pain, they can be used to successfully reduce a patient’s pain to a level at which he or she can function. With regular use however, their effectiveness generally declines, requiring the patient to take more medication for the same amount of pain relief. Because of this, it is important to use opioid medication sparingly in the management of neuropathic facial pain. Medications in this class include:

  • fentanyl
  • hydrocodone
  • hydromorphone
  • methadone
  • morphine
  • oxycodone
  • oxymorphone
  • tapentadol

For more information on any of these medications, please refer to www.drugs.com.

Owing to the high risk factors of both chemical dependency and abuse, opioid medications are Schedule II drugs in the United States. This class of medication is routinely vilified by government agencies, such as the CDC (see the Lawhern Files,) and regulated very strictly by the DEA, leading doctors become leery of writing opioid prescriptions. It is now standard practice for a doctor to refer his or her patients to a pain management professional at a “pain clinic” for opioid medications, limiting his or her liability.

Ketamine

Although relatively new to the chronic neuropathic facial pain arsenal, ketamine is an FDA approved anesthetic drug that has been used in hospitals worldwide since the 1960’s.  Ketamine treatment can help decrease activity in the overactive nerves and help regrow new, healthy connections. Some possible side-effects include dizziness, blurred vision, nausea, and hallucinations.


Editor’s Note:

Until recently, a patient was required to “fail” treatment on at least two different medications before other treatments would be considered. It was also standard for a physician to recommend a facial pain patient continue to use drug therapy until the medications were no longer effective against the pain. Because it is now widely believed that the odds of surgery success are more favorable when the patient has surgery soon after diagnosis, rather than waiting until drug treatment fails, early intervention is encouraged.


Journal Publications

Allsop, Matthew J. et al. “Diagnosis, Medication, and Surgical Management for Patients with Trigeminal Neuralgia: A Qualitative Study.” Acta Neurochirurgica 157.11 (1925–1932) 2015.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4604507/
McQuay,H.,Carroll D., R Jadad, A., Wiffen, P., Moore, A.,
“Anticonvulsant Drugs for Management of Pain: A Systematic Review
BMJ 1995;311:1047
http://www.bmj.com/content/311/7012/1047.short
Taylor, J. C., S. Brauer, and M. L. Espir. “Long-Term Treatment of Trigeminal Neuralgia with Carbamazepine.” Postgraduate Medical Journal 57.663 (16–18. Print) 1981.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2424760/
Oomens, M. A. E.-M., and T. Forouzanfar. “Pharmaceutical Management of Trigeminal Neuralgia in the Elderly.” Drugs and Aging 32.9 (717–726) 2015.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4579266/

Last updated 10/17