Timothy C. Hain, MD •Page last modified: August 20, 2020
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Neuralgia quite simply is pain caused by damage to nerves. It can be exquisitely painful.Trigeminal neuralgia is the most common type. The symptoms typically include lightning like jolts of pain in the face. The pain usually lasts for 10 seconds or less. It may be triggered by chewing, talking, or other facial movements. One may experience 100 attacks of trigeminal neuralgia throughout the day.
Similar but much less common to trigeminal neuralgia is glossopharyngeal neuralgia. Here, the nerve involved affects the throat and ear.
Post-herpetic neuralgia is also common. It is usually follows an attack of "zoster", which is a second attack of the chickenpox virus. About 15% of people who have had chickenpox develop zoster sometime during their life, and about 10% of people with zoster develop neuralgia. In older adults, as many as 50% develop neuralgia, one or more months after the rash. The pain of post-herpetic neuralgia is usually constant and burning.
Occipital neuralgia is usually due to trauma to the occipital nerve, often caused by a whiplasy type auto-accident. Here, there are paroxysms of severe occipital pain, that often resemble severe migraines. Occipital neuralgia can sometimes be successfully treated with blocks of the occipital nerve, sometimes followed by radio-frequency ganglioneurectomy. Medications are usually not helpful for occipital neuralgia.
In most instances no tests at all are needed. An MRI or CT scan of the skull base is the most common test.
Neuralgia can be extremely painful, and there are several approaches. In general a approach combining several classes of drugs is used.
Aspirin or acetominophen, nonsteroidal analgesics such as Torodol, and narcotics are frequently used for neuralgia. Usually non-narcotic pain killers are not strong enough to control neuralgia pain, but they are worth a try anyway. Narcotic medications are addictive and there is usually an attempt to use other medications first. However, it is clear that they are reasonably effective (Pappagallo and Campbell, 1994).
In general, topical treatment for nerve pain is a good idea. It avoids many side effects, and addiction.
These are commonly used for trigeminal neuralgia. Tegretol (carbamazepine), Dilantin (phenytoin), and Neurontin (gabapentin) are the most commonly used drugs (Robotham et al, 1998). The author of this review often uses Trileptal (oxcarbamazine). They are given in doses similar to used for epilepsy, but more leeway is given to the patient in adjusting the dose up and down, depending on the amount of activity of the neuralgia. Sodium Valproate has also been used for this purpose. Recently, oxcarbazepine (Trileptal) has become available. Although it is not FDA approved for this indication, it behaves similarly to carbamazepine. Adjunctive agents may be used in this situation. These include baclofen and amitryptyline (see following).
These are mainly used for post-herpetic neuralgia. Amitriptaline is the most commonly used. Nortryptaline, Desipramine and others can also be used. Some authors claim that amitryptaline should be started within 3-6 months of onset of shingles to get optimal relieve (Bowsher, 1994). SSRI type antidepressants don't appear to work according to one author (Max MB, 1994), and may be effective according to several others. SNRI type antidressants such as Cymbalta are used for neuropathic pain. It has been suggested that for this use, beta-blockers should be avoided (Yalcin et al, 2009)
Some authors feel that flareups of trigeminal neuralgia may be alleviated by use of acyclovir or better, closely related antiviral medications (e.g. famvir, valcyclovir). This indication is not well established, although it is clear that better results can be obtained if shingles is treated initially with Acyclovir. There are persistent reports suggesting that post-herpetic neuralgia is associated with persistent active virus (e.g. Pavan-Langson et al, 1995). This would suggest that antiviral treatment might be helpful.
More controversial is use of steroids during the zoster attack. While many physicians do use steroids, there is presently no evidence supporting less neuralgia in persons treated orally. (Calza et al, 1992). Epidural steroids have been reported to largely prevent post-herpetic neuralgia (1.6% vs. 22.2%, comparing epidural group to an intravenous group), but many persons might prefer not to be treated with medications administered in this somewhat invasive way, as ones chances are only about 1 in 5 of developing post-herpetic neuralgia.
In a trial of intrathecal steroids (given into the spinal canal) for post-herpetic neuralgia, Kotani and others (2000) reported that 91% of the a group with intractable post-herpetic neuralgia treated with methylprednisoline plus lidocaine experienced good to excellent relief.
A middle age woman experienced an automobile accident, and thereafter developed severe headaches with pain behind her right ear, nose bleeds, and loss of smell and taste. There was tenderness and wincing on palpation of the area behind the right ear. A tentative diagnosis of Eagles syndrome was proposed, but X-rays did not bear this out. Diagnostic blocks of the occipital nerve abolished the pain. She subsequently had RF-ganglioneurectomy, with complete relief of headache for 6 months.