Trigeminal neuralgia: successful antiepileptic drug combination therapy in three refractory cases

Drug, Healthcare and Patient Safety Dovepress open access to scientific and medical research C as e S e r i e s Drug, Healthcare and Patient Safety downloaded from https://www.dovepress.com/ by 213.32.48.132 on 12-Jul-2018 For personal use only. Open Access Full Text Article Trigeminal neuralgia: successful antiepileptic drug combination therapy in three refractory cases This article was published in the following Dove Press journal: Drug, Healthcare and Patient Safety 9 August 2011 Number of times this article has been viewed Lara Prisco 1 Mario Ganau 2 Federica Bigotto 1 Francesca Zornada 1 1 Department of Anaesthesiology, Intensive Care and Emergency Medicine, University Hospital of Cattinara, 2Graduate School of Nanotechnology, University of Trieste, Italy Abstract: Antiepileptic drug combination therapy remains an empirical second-line treatment approach in trigeminal neuralgia, after treatment with one antiepileptic drug or other nonantiepileptic drugs have failed. The results in three patients followed in our clinic are not sufficient to draw definitive conclusions, but suggest the possibility of developing this type of therapeutic approach further. Keywords: trigeminal neuralgia, antiepileptic drugs, combination therapy Introduction The annual incidence of trigeminal neuralgia is approximately 12.6 new cases per 100,000 people per year, with a female to male preponderance of 3:2.1 Trigeminal neuralgia is defined by the International Classification of Headache Disorders as paroxysmal attacks of pain (strong, sharp, superficial, or stabbing) lasting from a fraction of a second to 2 minutes, precipitated by stimulation of “trigger zones” or triggers with involvement of one or more divisions of the trigeminal nerve. The age of onset is 40–60 years for classic trigeminal neuralgia (idiopathic, not attributed to another disorder) and 30–40 years for symptomatic trigeminal neuralgia (secondary to compression of the trigeminal ganglion or to a demyelinating disorder). Several studies have investigated carbamazepine, gabapentin, and pregabalin for their effectiveness in the treatment of trigeminal neuralgia.2–4 Currently, the combination of antiepileptic drugs in the treatment of trigeminal neuralgia is a “second-line approach.” Antiepileptic drug treatment is sometimes considered when a combination of nonantiepileptic drugs fails. We report here three patients with trigeminal neuralgia who were successfully treated using a combination of antiepileptic drugs after failure of first-line and other therapeutic strategies. Case series Correspondence: Lara Prisco Via San Francesco 12, Trieste 34133, Italy Tel +39 34 0229 3558 Fax +39 040 823375 Email submit your manuscript | www.dovepress.com Dovepress http://dx.doi.org/10.2147/DHPS.S22385 Powered by TCPDF (www.tcpdf.org) The records of three patients (A, B, and C) diagnosed with trigeminal neuralgia and attending the Clinic for Pain Therapy at our institution were retrospectively reviewed, and appropriate information was collected. These patients were chosen as cases to report because of their refractory typical trigeminal neuralgia symptoms. Patients who did not require a combination of antiepileptic drugs to treat their symptoms were not included. The patients provided written consent for their information to be used for clinical research. Two patients were found to have trigeminal neuralgia secondary to ganglion compression (A and B) and the third patient had an idiopathic form (C). Drug, Healthcare and Patient Safety 2011:3 43–45 © 2011 Prisco et al, publisher and licensee Dove Medical Press Ltd. This is an Open Access article which permits unrestricted noncommercial use, provided the original work is properly cited. 43 Dovepress 44 Powered by TCPDF (www.tcpdf.org) submit your manuscript | www.dovepress.com Dovepress Tramadol 100 mg × 3/day Indomethacin 100 mg/day Tizanidine 4 mg/day Baclofen 25 mg/day GBP 100 mg × 3/day (7 months) III 48 F C II 67 M B Abbreviations: AED, antiepileptic drug; CT, combination therapy; VAS, visual analog scale (0–10); GBP, gabapentin; CBZ, carbamazepine; PGB, pregabalin; TENS, Transcutaneous Electrical Nerve Stimulation. Citalopram 10 mg/day Lormetazepam 0.25% 20 gtt/day Oxycodone 10 mg × 2/day Alphalipoic acid + vitamins 400 mg × 2/day Tramadol 150 mg/day Etoricoxib 90 mg/day PGB 75 mg + 25 mg/day (1 year) VAS 4 CBZ 300 mg + GBP 100 mg (7 months) VAS 1 VAS 0 CBZ 100 mg + PGB 75 mg (1 month) VAS 5 VAS 0 CBZ 100 mg + GBP 100 mg (1 month) Doxepine 10 mg/day Amitriptyline 4% 5 g/day F A 70 I, II, III Decompressive neurosurgical treatment Acupuncture (12 sessions) Trigeminal blockade with local anesthetic and cortisone Decompressive neurosurgical treatment Dental treatment Acupuncture (20 sessions) Sphenopalatine ganglion blockade (transnasal/ transoral) and infraorbital nerve blockade transoral) with local anesthetic and clonidine Trigger point injections with local anesthetic and clonidine TENS and laser sessions in trigeminal territory CBZ 200 5 mg/day (8 years) VAS 6 VAS after CT CT with AED (duration) VAS before CT Non-AEDs pharmacologic treatment Single AED treatment (duration) Nonpharmacologic treatments Trigeminal branch involved Trigeminal neuralgia causes episodes of paroxysmal pain that are short-lasting but intense in nature. The intervals between the paroxysms are generally free from painful symptoms, but a constant dull pain persists in some cases.5 Medical treatment of trigeminal neuralgia includes the use of antiepileptic drugs (carbamazepine, gabapentin, pregabalin, lamotrigine) and nonantiepileptic drugs (baclofen, tocainide, pimozide, clomipramine, amitriptyline, tizanidine, proparacaine). The most studied antiepileptic drugs in trigeminal neuralgia are carbamazepine, baclofen, lamotrigine, and pimozide.6 Recent studies have suggested the use of other antiepileptic drugs in trigeminal neuralgia, such as Age (years) Discussion Gender The pathophysiological characteristics and therapeutic management of the patients are summarized in Table 1. The two patients with secondary trigeminal neuralgia underwent neurosurgical decompression of the trigeminal ganglion and other minimally invasive treatment (nerve block and infiltration), in addition to several sessions of acupuncture which did not change either in intensity or type of pain. In a different tertiary clinic, all three patients had in the first instance taken antiepileptic monotherapy using various combinations of nonantiepileptic drugs for a period of 7 months to 8 years without obtaining satisfactory results in terms of pain relief, but experiencing various side effects due to the use of antidepressants (drowsiness), opioids (nausea and constipation), and nonsteroidal anti-inflammatory drugs (epigastralgia). The three patients were subsequently prescribed a combination of antiepileptic drugs for a period of 1–7 months. Carbamazepine was prescribed with gabapentin or pregabalin, ta (...truncated)