Trigeminal Neuralgia

Routine Referrals:

• Patients in whom trigeminal neuralgia is suspected and have any of the following features:
  • <40 years old; atypical clinical features (bilateral or V1 only); associated focal neurological deficits – these features increase the possibility of an underlying structural cause (such as MS) and imaging / review may be required
  • Failure to respond to 1st line therapy

Who we offer advice on:

• Facial pain not typical of trigeminal neuralgia
  • Consider allodynia of migraine, atypical/mid-segmental facial pain, or TMJ dysfunction.

SCI Gateway/Neurology

• Carbamazepine
  • Starting dose – 200mg
  • Titration – Increase by 200mg as required/tolerated every 3 days
  • Usual dose range – 600mg-800mg/daily. Not used in doses greater than 1200mg/daily for trigeminal neuralgia.
  • Frequency – Two to four times daily
  • Tapering – Reduce by 200mg every 7 days

• Alternative 1st line if carbamazepine not tolerated is Oxcarbazepine
  • Starting dose – 300mg
  • Titration – Increase by 300mg as required/tolerated every 3 days
  • Usual dose range – 600mg-1800mg/daily.
  • Frequency – Four times daily
  • Tapering – reduce by 300mg every 7 days

Second line therapies should be considered if there has been an incomplete response to 1st line treatment despite reaching maximal doses of Carbamazepine or Oxcarbazepine (or either are contraindicated/not tolerated). They can be used instead of, or in conjunction, with 1st line therapies:

• Lamotrigine – 1st choice of 2nd line therapy
  • Starting dose – 25mg
  • Titration – Increase by 25mg as required/tolerated every 1 week
  • Usual dose range – 25mg-400mg/daily
  • Frequency – Two times daily
  • Tapering – reduce by 50mg every 7 days

• Baclofen – 2nd choice of 2nd line therapy
  • Starting dose – 15mg (5mg tds)
  • Titration – Increase by 15mg as required/tolerated every 1 week
  • Usual dose range – 15mg-80mg/daily
  • Frequency – Three times daily
  • Tapering – reduce by 15mg every 7 days.