What medications are used to treat both trigeminal neuralgia and migraines?

Medications for Both Trigeminal Neuralgia and Migraine

Carbamazepine is the most effective medication for treating both trigeminal neuralgia and migraine, with strong evidence supporting its use for trigeminal neuralgia and some evidence for migraine prevention. 1, 2, 3

First-Line Medications

Anticonvulsants

• Carbamazepine (200-1200 mg/day divided in 2-3 doses) is the gold standard first-line treatment for trigeminal neuralgia with 70% of patients showing partial or complete pain relief 1, 2
• Oxcarbazepine is an alternative first-line agent for trigeminal neuralgia with a better side effect profile than carbamazepine 2, 3
• Gabapentin and pregabalin are effective for neuropathic pain conditions including trigeminal neuralgia and have shown efficacy in migraine prevention 1, 3
• Topiramate has demonstrated efficacy in both conditions, particularly at doses of 50-100 mg/day for trigeminal neuralgia 4, 5
• Valproate/divalproex sodium has good evidence for migraine prevention and may help with trigeminal neuralgia 1, 5

Tricyclic Antidepressants

• Amitriptyline (10-150 mg/day) has consistent evidence for migraine prevention and can be effective for neuropathic pain including trigeminal neuralgia 1
• Nortriptyline (25-100 mg/day) has shown encouraging results for neuropathic corneal pain and may be preferred over amitriptyline due to its superior side effect profile 1

Second-Line Medications

Other Anticonvulsants

• Lamotrigine can be used as add-on therapy for trigeminal neuralgia when first-line treatments are insufficient 3, 5
• Baclofen has shown efficacy in trigeminal neuralgia and can be considered when other options fail 1, 3

Botulinum Toxin

• OnabotulinumtoxinA (Botox) has demonstrated efficacy in both chronic migraine and trigeminal neuralgia 3, 6
• This option should be considered when oral medications are ineffective or poorly tolerated 6

Medication Selection Algorithm

1. Start with anticonvulsants:

   • For predominant trigeminal neuralgia: Begin with carbamazepine (200 mg at night, gradually increasing to 400-1200 mg/day divided in 2-3 doses) 1, 2
   • For predominant migraine: Consider topiramate (50-100 mg/day) or valproate/divalproex sodium 1, 4

2. If ineffective or poorly tolerated:

   • Switch to alternative anticonvulsant (oxcarbazepine, gabapentin, or pregabalin) 1, 3
   • Add tricyclic antidepressant (amitriptyline or nortriptyline) 1

3. For refractory cases:

   • Consider combination therapy with multiple anticonvulsants 3
   • Add baclofen or lamotrigine as adjunctive therapy 3, 5
   • Consider botulinum toxin injections 6

Common Pitfalls and Caveats

• Start anticonvulsants at low doses and titrate slowly to minimize side effects, particularly in older adults (e.g., pregabalin 25-50 mg/day or gabapentin 100-200 mg/day initially) 1
• Monitor for common side effects of anticonvulsants including drowsiness, dizziness, mental clouding, and ataxia 1
• Carbamazepine can cause serious adverse effects including blood dyscrasias, requiring regular monitoring 2
• Tricyclic antidepressants commonly cause dry mouth, constipation, and sedation; use with caution in elderly patients 1
• Valproate has teratogenic potential and should be avoided in women of childbearing potential 1
• Triptans, while effective for migraine, are not indicated for trigeminal neuralgia and should be avoided in patients with cardiovascular disease 1