Treatment of acute exacerbations of trigeminal neuralgia in the emergency department: A retrospective case series

Abstract

Objective: To evaluate the response to treatment of acute trigeminal neuralgia (TN) exacerbations in the emergency department (ED).Background: TN is characterized by recurrent and intense pain paroxysms. Some patients experience severe acute exacerbations requiring ED presentation. The optimal management of these episodes is not well established. Methods:We present a case series of TN exacerbations in adults who presented to the ED of a tertiary center from January 2008 to December 2020. We analyzed demographic and clinical data, including pharmacological management in the ED. The primary outcome was pain relief, classified into "no relief," "partial relief," and "satisfactory relief" based on the qualitative description in the ED's records. Results:Ultimately 197 crisis episodes corresponding to 140 patients were included.Most were women (61%, 121/197) with a median age of 63 years (interquartile range: 52-73). Acute TN exacerbations were treated with opioids in 78% (108/139) of crisis episodes, nonsteroidal anti-inflammatory drugs in 42% (58/139), corticosteroids in 21% (29/139), intravenous phenytoin in 18% (25/139), and intravenous lidocaine in 6% (8/139). Of the 108 cases treated with opioids, 78 (72%) required additional drugs for pain management. Intravenous phenytoin allowed satisfactory pain relief in 64% of cases. Conclusion:In our sample, opioids were the most used therapeutic approach in acute TN exacerbations despite their low efficacy and subsequent need for further drug treatment in most cases. Most crisis episodes managed with intravenous phenytoin reached total pain relief. Prospective studies are needed to guide the treatment of acute exacerbations of TN.

Lidocaine aerosol sprayed on oral and/or nasal mucosa for the rescue of acute trigeminal neuralgia exacerbations: A retrospective study

“…The findings of this study indicate that over 70% of patients treated with intraoral and/or intranasal lidocaine 2.4% spray reported a 50% or more reduction in pain intensity without any serious side effect for acute TN exacerbations. This rate is comparable with that reported for intravenous lacosamide and phenytoin (25), intravenous lidocaine (5,26) and lidocaine nerve block (9). To our knowledge, this is the first study that reports the clinical efficacy and safety of lidocaine sprayed directly to the oral and/or nasal mucosa for TN exacerbation, and the number of cases was the largest to this date.…”

“…Acute TN exacerbation is a common reason for frequent visits to the emergency department, that often occur while waiting for surgery, but evidence on effective drugs in acute TN attacks is scant and no option is considered the gold standard up to now. Treatment options such as lidocaine (topical or systemic application), anticonvulsant (intravenous infusion), phenytoin or fosphenytoin (intravenous infusion), serotonin agonist (subcutaneous injection), sumatriptan (subcutaneous injection) and botulinum toxin (trigger point injection) are beneficial for acute exacerbations of TN (4–6), but evidence-based studies are scarce and future investigations should report on outcomes within 24h to improve knowledge of the acute TN exacerbation treatments.…”