Gabapentin Supplemented With Ropivacain Block of Trigger Points Improves Pain Control and Quality of Life in Trigeminal Neuralgia Patients When Compared With Gabapentin Alone

Abstract

Objective: Pain control in trigeminal neuralgia (TN) is achieved using anticonvulsivants, mainly carbamazepine. When this drug cannot be used, other drugs like gabapentin (GBP) have been used to provide adequate pain control. To improve the therapeutic effect of GBP, we evaluated the clinical efficacy of associating GBP with ropivacain (ROP) analgesic block of facial trigger points in TN patients.Design: Thirty-six TN patients were randomly assigned during 4 weeks to 1 of the following protocols: Protocol I-daily oral GBP administered in a titrated dose; Protocol II-ROP applied as analgesic block to TN trigger points once a week; Protocol III-daily oral GBP plus ROP once a week. Protocol II had to be discontinued in 7/12 patients owing to insufficient pain control. Pain intensity was evaluated by the Visual Analog Scale (VAS) and disability was assessed by Sickness Impact Profile.Results: When compared with Protocol I, Protocol III (GBP+ROP) patients showed (1) a reduction of VAS score after 7 and 28 days of treatment, an effect that was still present 6 and 12 months later; (2) a faster reduction of VAS score using a significantly lower dose of GBP; (3) a smaller total and daily GBP dose at the end of the treatment, which resulted in a total absence of adverse side effects; and (4) an improvement of the functional well-being measured by the Sickness Impact Profile. The number needed to treat (NNT) (GBP+ROP vs. GBP protocols) to obtain 1 GBP+ROP-treated patient with at least 50% pain relief was 1.71 (day 7) and 2.40 (day 28). Conclusions:The association of GBP and ROP is safe, without side effects and results in an important clinical benefit associated to an improvement of the functional health status of TN patients when compared with GBP alone. This may constitute a therapeutic alternative for pain control in TN patients who cannot be treated with carbamazepine.

Medical management of trigeminal neuropathic pains

“…Although I have used gabapentin as a third-line drug, I have had disappointing results with it and have had to use much higher dosages than those reported in the randomized controlled trial [42]. Although the side effects of gabapentin are quoted as being low, weight gain and oedema seem to be more frequently reported than when using other anticonvulsants.…”

“…It is therefore not surprising that it has been reported in trigeminal neuralgia in several open studies [38,39] and reviewed [40,41]. Only one RCT used it in combination with ropivacain [42]. Although considerable effort was placed on allocation concealment and randomization, the study was only single blinded as patients knew whether they received an injection.…”

Treatment options in trigeminal neuralgia

“…Gabapentin showed adequate efficacy alone and in combination with local injections of ropivacaine used to block trigger points in TN patients. Even though only 36 patients were investigated, this combination seems safe and effective in the treatment of TN [Lemos et al 2008]. Gabapentin is initiated at 300 mg daily and may be gradually increased by 300 mg each 23 days as tolerated.…”

Combination of pharmacotherapy and lidocaine analgesic block of the peripheral trigeminal branches for trigeminal neuralgia: a pilot study

“…Eleven of 35 patients in the cited study experienced complete pain relief and general pain scores following the analgesic block were markedly reduced compared to pre-treatment scores. The other study by Lemos et al evaluated the protocol of gabapentin in association with ropivacaine block 8 . The clinical benefit in this combination management was found to be improvement of visual analogue scores (VAS) of pain until 28 days after the treatment.…”

“…As an alternative management, trigeminal nerve block with local anaesthetics could be considered in combination with pharmacotherapy 7,8 . The scope of this study was to evaluate the clinical benefit of combination of pharmacotherapy and lidocaine analgesic block in CTN patients.…”