Trigeminal Neuralgia Medications

Medication	Dose range	Labs / monitor	Side effects
Carbamazepine	Start at 100 mg BID and increase by 100 mg/day until decrease in pain or noted signs of toxicity. Divided doses Maximum dose: 1200 mg Maintenance dose : 600-1200 mg/day Monitoring in therapeutic range (4 to 12mg/ml) also check electrocardiogram to look for arrhythmias and eval QT interval	Before starting: CBC and liver function tests (CMP will include this) Perform blood once a month for 3 months and then once every 3-6 months after Screen for patients genetically at risk HLA-B1502 (Asian patients) Aplastic anemia 1 in 200,000 -10% develop leukopenia, neutropenia, thrombocytopenia liver toxicity Steven Johnsons! Also remember to ask for MRI w/and w/o contrast to include cerebellopontine and brainstem when TN is suspected	Rash, sedation, vertigo, blurred vision, ataxia, gastric distress, confusion, decreased mental acuity, inducer of CYP450 3A4 Slow release has fewer side effects DO NOT USE IN PATIENTS WHO ARE ADVERSELY SENSITIVE TO TCA’S AS IT HAS SIMILAR STRUCTURE Take with food Pts with low pre-tx WBC counts are increased risk of leukopenia (WBC<3000/mm3) look for signs of hematologic toxicity (infections, fatigue, ecchymosis and abnormal bleeding)
Oxcarbazepine	Start with 150 mg at bedtime or BID; increase by 150 mg/day every 3-4 days to daily dose of 300-600 mg/day BID Therapeutic range: 1500-1800 mg/day in divided doses MAX dose: 2400 mg/day	Basic Metabolic Panel (Blood sodium) Normal range of serum Na: 135-145 mEq/L Hyponatremia (below 131) Signs of hyponatremia: nausea, vomiting, lethargy, fatigue, appetite loss, restlessness, irritability, headache, confusion, muscle weakness	Somnolence, dizziness *American Academy of Neurology recommends this as first line DON'T USE IN PATIENTS SENSITIVE TO CARBAMAZEPINE
Gabapentinoids (Gabapentin)	300 mg/day titrated up slowly by 300 mg/day every 3-5 days (go from 300 mg/day q 1 day, then 300 mg BID for 1 day then 300 mg TID) you can start it as low as 100 mg/day to avoid sedation -administer it TID for effective blood level Maximum dose: 3600 mg	Monitor blood pressure in HTN patients (b/c of fluid retention) Lower dose in pts with renal insufficiency, B/c the kidneys excrete it.	Sedation, dizziness, ataxia, fluid retention
Gabapentinoids (pregabalin)	Start 25 mg TID; increase to 100-200 TID		Helps with sleep!
Nortriptyline/Pamelor, Noritren	Start 10 mg at bedtime; increase to 50-70 mg	EKG in patients over 40 Contraindicated in patients with narrow angle glaucoma, urinary retention, benign prostatic hypertension, impaired liver function, cardiovascular disease (ischemic cardiac disease, MI)	Xerostomia, blurred vision, constipation, urinary retention, postural hypotension, compensatory reflex tachycardia, memory dysfxn, cardiac depression, cardiac electrical conduction problems, arrhythmias
Baclofen/Lioresal – this is in conjunction with Carbamazepine/Oxcarb	Start at 5 mg TID; increase slowly by 5mg q 2-3 days to max of 80 mg/day		Ataxia, dizziness, mental confusion DO NOT discontinue abruptly bc of chance of hallucinations, anxiety and tachycardia
Duloxetine/Cymbalta instead of Nortriptyline	Start 20 mg at bedtime; increase to max of 60 mg/day
Lamitrigine/Lamictal	25mg/day BID increased gradually to maintenance doses of 200-400mg/d.	Titrate slowly guided by response and adverse effects. Risk of Steven-Johnson syndrome can be minimized with gradual titration.	Sleepiness, dizziness, headache, vertigo and ataxia, rash. Long term tx can lead to Steven’s Johnson Syndrome, toxic epidermal necrolysis and visual bluring.
Levetiracetam/Keppra	500mg twice daily, max 3000mg/day; increase dosage every 2 weeks by 500 mg twice daily based on response and tolerability.	Bloodwork CBC/Dif, liver function and electrolytes.
Clonazepam/Klonopin	0.5mg at bedtime, maintance dose 4mg	Some physicans recommend periodic blood cell and Liver function tests	Sedation and cognitive function, especially in the elderly