24. Neuralgia treatment

• First-line treatment: choose from one of the following

  • Carbamazepine

  • Oxcarbazepine

• Other anticonvulsants (e.g., lamotrigine, oxcarbazepine, baclofen, phenytoin, gabapentin) may be used on an individual basis.

• Treatment should be initiated and supervised by neurological specialists.

• Consider lidocaine infusion (only under the direction of an experienced physician) with continuous cardiac monitoring. [12][16]

• Further treatment options include : [16]

  • Phenytoin or fosphenytoin infusion

  • Oral or nasal application of lidocaine

  • Local anesthetic trigger point injection

  • Sumatriptan (SQ, nasal, or oral)

• First-line treatment for focal seizures

• First-line treatment of trigeminal neuralgia

• Second-line treatment for generalized tonic-clonic seizures

First-line anticonvulsant

• Inactivates Na+ channels

• Nausea

• Rash

• Hyponatremia, hyperhydration, and edema (due to SIADH)

• DRESS syndrome

• Blood count abnormalities (e.g., agranulocytosis, aplastic anemia)

• Teratogenicity during the first trimester (cleft lip/palate, spina bifida) (see pharmacotherapy during pregnancy)

• Diplopia

• Ataxia

• Hepatotoxicity

• Stevens-Johnson syndrome

• Induces cytochrome P450

• Pregnancy (especially valproate and carbamazepine)

• Strong induction of cytochrome P450

Also first line anticonvulsant

• Tonic-clonic seizures

• Only rarely used for long-term treatment of focal seizures

• Treatment of established status epilepticus[2]

• Inactivation of Na+ channels

• Zero-order elimination (i.e., constant rate of drug eliminated)

• Hirsutism

• Hyperpigmentation of skin (melasma)

• Gingival hyperplasia

• Nystagmus

• Osteopenia

• Megaloblastic anemia due to ↓ folate absorption

• Peripheral neuropathy

• Stevens-Johnson syndrome

• Drug-induced lupus erythematosus

• DRESS syndrome

• Intoxication: sedation, diplopia, ataxia, arrhythmias

• Induction of cytochrome P-450 enzymes

• Teratogenic: fetal hydantoin syndrome

• Hypothyroidism

Pregnancy

• Induction of cytochrome P450

Second generation anticonvulsant.

• Second-line treatment for focal seizures

• Postherpetic neuralgia

• Peripheral (poly)neuropathy

• Drug combination for long-term treatment of focal seizures

• Neuropathic pain

• Neuralgia after herpes infection

• Generalized anxiety disorder

• Inhibition of presynaptic P/Q-type Ca2+ channels via action on the α2δ-subunit → ↓ Ca2+ intracellular flow → ↓ glutamate release [1]

• Does not bind to GABA receptors despite being a GABA analog

• Somnolence

• Nausea

• Ataxia

• Impaired vision

• Dry mouth

• Somnolence, nausea

• Ataxia

Hypersensitivity