What is the treatment approach for patients with both trigeminal neuralgia and extreme tinnitus?

From the Guidelines

The treatment approach for patients with both trigeminal neuralgia and extreme tinnitus typically involves addressing each condition separately while being mindful of potential medication interactions, with carbamazepine being a first-line treatment for trigeminal neuralgia, as supported by a systematic review 1. For trigeminal neuralgia, anticonvulsant medications such as carbamazepine (starting at 200mg at night and gradually increased by 200mg every 7 days to a final dose of 400–1200 mg, divided in 2–3 doses per day) are commonly used, with a study demonstrating that 70% of carbamazepine-treated patients showed partial or complete pain relief 1. Other treatment options for trigeminal neuralgia include oxcarbazepine, lamotrigine, and baclofen, as well as surgical interventions like microvascular decompression or gamma knife radiosurgery for refractory cases, with microvascular decompression having a 70% chance of being pain-free at 10 years 1. For severe tinnitus, treatment options include tricyclic antidepressants like amitriptyline, benzodiazepines such as clonazepam, or sound therapy using hearing aids or masking devices, with cognitive behavioral therapy being recommended for patients with persistent, bothersome tinnitus, as it has a preponderance of benefit over harm 1. When treating both conditions simultaneously, physicians must carefully monitor for side effects and drug interactions, particularly when combining anticonvulsants with antidepressants or benzodiazepines. Some key points to consider in the treatment plan include:

• Individualizing the treatment plan based on symptom severity, comorbidities, and patient preferences
• Regular follow-up to assess efficacy and adjust medications as needed
• Avoiding transcranial magnetic stimulation (TMS) for the routine treatment of patients with persistent, bothersome tinnitus, as it has inconclusive RCTs 1.

From the FDA Drug Label

Carbamazepine tablets are indicated in the treatment of the pain associated with true trigeminal neuralgia. Beneficial results have also been reported in glossopharyngeal neuralgia.

The treatment approach for patients with both trigeminal neuralgia and extreme tinnitus is not directly addressed in the provided drug labels.

• Trigeminal Neuralgia: The initial dose of carbamazepine for trigeminal neuralgia is 100 mg twice a day, with a maximum daily dose of 1200 mg.
• Extreme Tinnitus: There is no information in the provided drug labels that directly supports the treatment of extreme tinnitus with carbamazepine. Since the FDA drug label does not provide direct information on the treatment of extreme tinnitus, a conservative clinical decision would be to consult other relevant medical resources or guidelines for the treatment of extreme tinnitus 2 2.

From the Research

Pathology of Trigeminal Neuralgia and Extreme Tinnitus

• Trigeminal neuralgia is a rare condition characterized by sudden, brief, and excruciating facial pain attacks in one or more of the branches of the trigeminal nerve 3.
• The etiology of trigeminal neuralgia can be classified into idiopathic, classic, and secondary, with classic trigeminal neuralgia associated with neurovascular compression in the trigeminal root entry zone 3.
• Extreme tinnitus, on the other hand, is a condition characterized by a persistent and debilitating ringing or other sound in the ears.
• There is limited research on the direct relationship between trigeminal neuralgia and extreme tinnitus, but some studies suggest that patients with trigeminal neuralgia may also experience tinnitus 4.

Treatment Approach for Patients with Both Trigeminal Neuralgia and Extreme Tinnitus

• The treatment approach for patients with both trigeminal neuralgia and extreme tinnitus typically involves a combination of pharmacological and non-pharmacological interventions.
• For trigeminal neuralgia, antiepileptic drugs such as carbamazepine and oxcarbazepine are commonly used as first-line treatments 4, 5, 3, 6, 7.
• Other drugs such as gabapentin, pregabalin, lamotrigine, and phenytoin may also be used as adjunctive therapies or in patients who do not respond to carbamazepine or oxcarbazepine 3, 6.
• For extreme tinnitus, treatment options may include sound therapy, cognitive behavioral therapy, and pharmacological interventions such as antidepressants or anticonvulsants.
• In patients with both trigeminal neuralgia and extreme tinnitus, a multidisciplinary approach involving neurologists, otolaryngologists, and other specialists may be necessary to develop an effective treatment plan.

Pharmacological Treatment Options

• Carbamazepine and oxcarbazepine are effective in reducing pain in patients with trigeminal neuralgia, but may have side effects such as dizziness, drowsiness, and nausea 4, 5, 7.
• Combination therapy with multiple drugs may be necessary in some patients, but requires careful monitoring for potential drug interactions and side effects 4, 6.
• New pharmacological alternatives such as eslicarbazepine and vixotrigine are being explored for the treatment of trigeminal neuralgia, but more research is needed to determine their efficacy and safety 3.