Trigeminal neuralgia or tic douloureux represents one of the most common forms of facial pain; according to the recent systematic review of the literature by De Toledo, the prevalence would be higher in the female population, subject to a prevalence between 0.03% and 0.3% and in a ratio of 3:1 compared to the male population and more in the age range between 37 and 40 years.
The International Headache Society contemplates an atypical form, but the distinctive feature of the disease consists the appearance of episodes of “electric-shock-like” pain, spontaneous or unleashed during daily activities (such as touching the face, eating-drinking or brushing the teeth), which are usually followed by periods of refractoriness. The territories most frequently affected are those of the second and third branches of the V pair of cranial nerves (maxillary and mandibular respectively).
There are several options proposed – even effectively – to treat the condition; carbamazepine is the most effective drug but has adverse effects in 70% of patients who respond. In the therapeutic complex of trigeminal neuralgia, in fact, it is quite frequent to meet patients who have become secondary to the first therapeutic line. Therapies that are not strictly pharmacological have also been proposed, such as knife gamma radiosurgery. Among the drugs, the possibility of administering local amide anesthetics (lidocaine, ropivacaine, and bupivacaine), effective on the different nerve branches, has been described in various ways, also in terms of results. This is an option contemplated precisely in the forms of pathology refractory to the first pharmacological lines.
A specific example is the one documented by Gornitsky in a case report recently published in Special Care in Dentistry. The article refers to a total of 3 patients of the Jewish General Hospital of Montreal, Canada, suffering from forms of neuralgia of the maxillary branch that do not respond to conventional therapy, based on the administration of high doses of carbamazepine, namely, gabapentin and pregabalin. All subjects underwent a common technique of nervous blockage of the corresponding palatine area by the administration of local anesthetic at the level of the large palatine hole.
The aim of the treatment is to extend the periods of refractoriness, which would last well beyond the end of the duration of action of the single administration. This is rather indicative of the need within this type of therapy to “break the cycle of pain,” especially in the long term. This would be a simple option in the management of complex cases, which would be treated, among other things, with the advantage of savings in the dosage of the basic drug.