For patients and caregivers
There may be times you have a facial pain emergency- pain so severe you need to go to the hospital emergency room for treatment. If you are experiencing an acute attack of pain symptoms, remember that narcotics usually will not work to relieve your pain. Furthermore, you may not be able to take more of your prescribed antiepileptic ant-iconvulsive drugs (opening or touching your mouth may be a tactile pain trigger, and these drugs enter your system too slowly). In an emergency, seek medical attention at your local hospital that treats your condition. To avoid a prescription for narcotics, you may need to educate the ER staff about your facial pain. Some patients find it useful to keep a copy of these instructions with them to give to ER staff.
To the senior emergency room physician:
Recommended crisis management plan for patients presenting with an attack of neuropathic pain from TN
The key drug to use for facial pain is an anticonvulsant that can be loaded intravenously. Phenytoin (Dilantin) was the first TN drug discovered. Use a 1-gram IV drip over 20 minutes with EKG & BP monitoring, which will break the pain cycle more than 90% of the time. Fosphenytoin can also be used. Then you can advise patients to take more of their prescribed oral anticonvulsive drugs. If Dilantin does not work, two other anticonvulsive drugs can be administered intravenously: levetiracetam (Keppra) or Lacosamide (Vimpat). While not proven in trials for TN treatment, they are in the same family of drugs and may be safely and quickly loaded intravenously.
Key Points
Neuropathic pain usually DOES NOT respond to opioids, narcotics, or standard analgesics.
It is usually managed with PO anticonvulsants which take days to weeks to achieve an effective drug level. In the hospital setting, the patient has come to you because his or her pain has broken through the medication, because pain prevents them from taking PO meds, or they are not on the right drugs.
Immediate Action Required
- Plan A: Administer phenytoin (Dilantin) 1 gram IV over at least 20 minutes (with EKG and BP monitoring) to interrupt the pain cycle (or, alternatively, Fosphenytoin 1-gram Dilantin equivalent).
- Plan B: Administer levetiracetam (Keppra) 1000 mg IV over 5 minutes with EKG and BP monitoring.
- Plan C: Administer Lacosamide (Vimpat) 200–400 mg IV with EKG and BP monitoring.
If the pain does not respond to Dilantin, then Keppra or Vimpat are also suitable substitutes since they are in the same family of drugs which can be rapidly administered safely by an IV solution/drip.
