What is included in the long-term monitoring of trigeminal neuralgia (TN)?

Updated: Jul 11, 2019
  • Author: Manish K Singh, MD; Chief Editor: Robert A Egan, MD  more...
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Longitudinal follow-up care is important because of the chronicity of trigeminal neuralgia, and because many treatments fail to maintain their efficacy (eg, pharmacologic, procedural).

In patients treated with carbamazepine or phenytoin, obtain a blood count during the first few weeks of therapy (ie, monthly for at least 3 mo for carbamazepine, once after 2 wk for phenytoin), every time the dose is adjusted or adverse effects appear, and yearly thereafter. Agranulocytosis and aplastic anemia are extremely rare adverse effects, but suppression of the white blood cell (WBC) count in the range of 2000-3000 103/µL is not uncommon. This mild suppression of the WBC count does not warrant discontinuation of carbamazepine therapy. Hepatic function should also be monitored. Up to 70% of patients receive complete or acceptable partial relief, at least temporarily.

Oxcarbazepine is a newer agent that may have fewer side effects, but it can cause hyponatremia, which should be monitored with serial serum sodium measurements in the first few weeks of therapy.

Patients who experience breakthrough pain may need an increase in the dosage of their medication, if tolerated, or the addition of a second anticonvulsant medication or baclofen. No published data from randomized, prospective, controlled studies are available to guide clinicians regarding multidrug therapy, leaving providers to empiric trials of one agent or another.

Neurologists caring for younger patients (< 60 y at onset) should consider early neurosurgical consultation, even after a negative magnetic resonance image (MRI) of the brain. Surgical procedures occasionally can afford complete relief, delaying the need for anticonvulsant medications for many years, if not permanently.

Monitoring patients after procedures or open skull surgery helps screen for complications such as corneal abrasions and anesthesia dolorosa.

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