Painful Cranial Neuropathies

Abstract

The evidence base for drug management for these rare conditions is low due to the lack of high-quality randomised controlled trials (RCTs). Carbamazepine and oxcarbazepine have been shown to be highly effective in trigeminal neuralgia and are considered to be the first-line drugs. However, they do have significant side effects and their efficacy diminishes with time. Many other anti-epileptics (AEDs) can be used but their efficacy is not as high and their use often leads to delay in seeking a neurosurgical approach. Patients who have trigeminal neuralgia and multiple sclerosis may benefit from the use of increased doses of baclofen which they are already using. The drugs all need slow escalation to reduce side effects. The same drug regimens are used for glossopharyngeal neuralgia. Post-herpetic neuralgia of the face can be managed along the international guidelines for post herpetic neuralgia. In this area, there are large RCTs although it has been highlighted that the large placebo responses and poor phenotyping may be resulting in better outcomes than those found in clinical practice. The current most effective drugs are gabapentin, pregablin and tricyclic antidepressants. Topical lidocaine 5 % patches may be helpful in those patients who cannot tolerate systemic drugs. Treatments need to be optimised for individual patients and should be discontinued after adequate dosages and duration of use.