A systematic review of rescue analgesic strategies in acute exacerbations of primary trigeminal neuralgia

D Moore, M S Chong, A Shetty, J M Zakrzewska, D Moore, M S Chong, A Shetty, J M Zakrzewska

Abstract

Background: Trigeminal neuralgia (TN) can have a significant impact on wellbeing and quality of life. Limited data exist for treatments that improve TN pain acutely, within 24 h of administration. This systematic review aims to identify effective treatments that acutely relieve TN exacerbations.

Methods: We searched Medline and Cochrane Central Register of Controlled Trials (CENTRAL) for relevant English language publications. The reference list for all articles was searched for other relevant publications. All studies that satisfied the following PICO criteria were included: (i) Population-adults with acute exacerbation of primary TN symptoms; (ii) Intervention-any medication or intervention with the primary goal of pain relief within 24 h; (iii) Comparator-usual medical care, placebo, sham or active treatment; (iv) Outcome-more than 50% reduction in pain intensity within 24 h of administration.

Results: Of 431 studies, 17 studies were identified that reported immediate results of acute treatment in TN. The evidence suggests that the following interventions may be beneficial: local anaesthetic, mainly lidocaine (ophthalmic, nasal or oral mucosa, trigger point injection, i.v. infusion, nerve block); anticonvulsant, phenytoin or fosphenytoin (i.v. infusion); serotonin agonist, sumatriptan (s.c. injection, nasal). Other referenced interventions with very limited evidence include N-methyl-d-aspartate receptor antagonist (magnesium sulphate infusion) and botulinum toxin (trigger point injection).

Conclusions: Several treatment options exist that may provide fast and safe relief of TN. Future studies should report on outcomes within 24 h to improve knowledge of the acute analgesic TN treatments.

Keywords: acute pain; anticonvulsant; drug therapy; humans; local anaesthetic; serotonin agonist; treatment outcome; trigeminal neuralgia.

Conflict of interest statement

JMZ has a consultancy with Biogen.

Copyright © 2019 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.

Figures

Fig. 1
Fig. 1
Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) flow diagram details the literature search. Of 452 potentially relevant studies, 17 studies investigated or referenced the efficacy of an analgesic therapy within 24 h of administration for trigeminal neuralgia. TN, trigeminal neuralgia.
Fig. 2
Fig. 2
Risk of bias summary—review authors' judgements about each risk of bias item for the included RCTs.
Fig. 3
Fig. 3
Evidence-based treatment algorithm for the management of acute exacerbations of trigeminal neuralgia. Management of acute exacerbations should proceed in parallel with a more definitive long-term management plan. The quality of evidence is included after each intervention. The moderate- and high-quality evidence receives a ‘should consider’ recommendation. The very low- and low-quality evidence are options that the clinician ‘may consider’ if interventions with higher quality evidence are contraindicated or not available. *Sumatriptan injection pens in the UK contain 6 mg in 1 ml, and we have recommended this for convenience as opposed to the 3 mg used by the Japanese group. †These concentrations may not be available in all countries (2–5% more common). TN, trigeminal neuralgia.

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