Tratamento famacológico da neuralgia do trigêmeo: revisão sistemática e metanálise

Túlio César Azevedo Alves; Giselli Santos Azevedo; Emannuela Santiago de Carvalho

doi:10.1590/S0034-70942004000600015

Review Article

Tratamento famacológico da neuralgia do trigêmeo: revisão sistemática e metanálise

Pharmacological treatment of trigeminal neuralgia: systematic review and metanalysis

Túlio César Azevedo Alves; Giselli Santos Azevedo; Emannuela Santiago de Carvalho

http://dx.doi.org/10.1590/S0034-70942004000600015 Braz J Anesthesiol, vol.54, n6, p.836-849, 2004

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Resumo

JUSTIFICATIVA E OBJETIVOS: A neuralgia do trigêmeo é uma síndrome de dor crônica, caracterizada por paroxismos de dor excruciante que afeta de maneira dramática a qualidade de vida dos pacientes acometidos. A terapia medicamentosa sistêmica é considerada o tratamento de primeira linha para esta doença. Este estudo teve como objetivo avaliar a eficácia, a segurança e a tolerabilidade dos diversos tratamentos farmacológicos oferecidos aos pacientes com neuralgia do trigêmeo, visando fornecer evidências para as recomendações da prática clínica e identificar as necessidades de pesquisas adicionais. MÉTODO: Foram analisados ensaios clínicos aleatórios e controlados, publicados até julho de 2003, sobre o efeito analgésico das drogas prescritas no tratamento da neuralgia do trigêmeo. A análise estatística foi realizada com o auxilio do programa Review Manager 4.2.2 (Colaboração Cochrane, 2003). RESULTADOS: Os resultados da metanálise sugerem que a carbamazepina é mais eficaz que o placebo. Em três estudos controlados comparando a lamotrigina, o topiramato e o cloridrato de proparacaína ao placebo, somente a lamotrigina mostrou-se superior a ele. O dextrometafano foi comparado ao lorazepam em baixas doses, havendo aumento da dor com o uso daquele fármaco. Três estudos compararam a carbamazepina com a tizanidina, a tocainida e a pimozida, mostrando-se apenas a pimozida superior à carbamazepina. CONCLUSÕES: A carbamazepina continua como droga de escolha para o tratamento da neuralgia do trigêmeo, estando a lamotrigina e a pimozida indicadas em casos refratários à terapia convencional. Além disso, estudos adicionais são necessários para o estabelecimento de futuras opções terapêuticas.

Palavras-chave

DOR, DOR, TERAPÊUTICA

Abstract

BACKGROUND AND OBJECTIVES: Trigeminal neuralgia is a syndrome of chronic pain, characterized by paroxysms of excruciating pain which dramatically affect patients' quality of life. Systemic drug therapy is the first line treatment for this disease. This study aimed at evaluating efficacy, safety and tolerability of several pharmacologic treatments offered to trigeminal neuralgia patients, trying to supply evidences for clinical practice recommendations and to identify the needs for further research. METHODS: Randomized controlled clinical trials on the analgesic effects of drugs prescribed for trigeminal neuralgia were evaluated. All of them were published until July 2003. Statistical analysis was accomplished with the support of Review Manager 4.2.2 software (Cochrane Collaboration, 2003). RESULTS: Metanalisys results suggest that carbamazepine is more efficient than placebo. In three controlled studies comparing lamotrigine, topiramate and 0.5% proparacaine hydrochloride, only lamotrigine was superior to placebo. Dextromethorphan was compared to low-dose lorazepam, with increased pain with dextromethorphan. Three studies have compared carbamazepine to tizanidine, tocainide and pimozide, and only pimozide was superior to carbamazepine. CONCLUSIONS: Carbamazepine is still the drug of choice for treating trigeminal neuralgia, being lamotrigine and pimozide indicated for cases refractory to conventional therapy. In addition, further studies are needed to determine future therapeutic options.

Keywords

PAIN, PAIN, THERAPEUTIC

Referências

Zakrzewska JM, Jassim S, Bulman JS. A prospective, longitudinal study on patients with trigeminal neuralgia who underwent radiofrequency thermocoagulation of the Gasserian ganglion. Pain. 1999;79:51-58.

Devor M, Amir R, Rappaport ZH. Pathophysiology of trigeminal neuralgia: the ignition hypothesis. Clin J Pain. 2002;18:4-13.

Kitt CA, Gruber K, Davis M. Trigeminal neuralgia: opportunities for research and treatment. Pain. 2000;85:3-7.

Katusic S, Beard CM, Bergstralh E. Incidence and clinical features of trigeminal neuralgia, Rochester, Minnesota, 1945-1984. Ann Neurol. 1990;27:89-95.

Beal MF, Hauser SL. Distúrbios Comuns dos Nervos Cranianos. Medicina Interna. 2002:2572-2576.

Adams RD, Victor M. Neurologia. 1996:831-839.

Zakrzewska JM. Trigeminal, Eye and Ear Pain. Wall & Melzack - Textbook of Pain. 1999:739-760.

Kondziolka D, Lunsford LD, Flickinger JC. Stereotactic radiosurgery for the treatment of trigeminal neuralgia. Clin J Pain. 2002;18:42-47.

Peters G, Nurmikko TJ. Peripheral and gasserian ganglion-level procedures for the treatment of trigeminal neuralgia. Clin J Pain. 2002;18:28-34.

Zakrzewska JM, Chaudhry Z, Nurmikko TJ. Lamotrigine (lamictal) in refractory trigeminal neuralgia: results from a double-blind placebo controlled crossover trial. Pain. 1997;73:223-230.

Clarke M, Oxman AD. Cochrane Reviewers Handbook 4.2.0. 30 A.

Jadad AR. Randomized Controlled Trials. 1998.

Arieff AJ, Wetzel N. Tegretol in the treatment of neuralgias. Dis Nerv Syst. 1967;28:820-823.

Kienast HW, Boshes LD. Clinical trials of carbamazepine in suppressing pain. Headache. 1968;8:1-5.

Davis EH. Clinical trials of tegretol in trigeminal neuralgia. Headache. 1969;9:77-82.

Rasmussen P, Riishede J. Facial pain treated with carbamazepin (Tegretol). Acta Neurol Scand. 1970;46:385-408.

Westerholm N. Treatment of facial pain with G 32 883 (Tegretol Geigy). Scand J Dent Res. 1970;78:144-148.

Peiris JB, Perera GL, Devendra SV. Sodium valproate in trigeminal neuralgia. Med J Aust. 1980;2:278.

Steardo L, Leo A, Marano E. Efficacy of baclofen in trigeminal neuralgia and some other painful conditions. A clinical trial. Eur Neurol. 1984;23:51-55.

Castaneda C, Altamirano J, Sagastegui A. Ensayo terapéutico en las crisis de dolor radicular. Rev Neuropsiquiatr. 1986;49:83-88.

Farago F. Trigeminal neuralgia: its treatment with two new carbamazepine analogues. Eur Neurol. 1987;26:73-83.

Zurak N, Randic B, Poljakovic Z. Intravenous chlormethiazole in the management of primary trigeminal neuralgia resistant to conventional therapy. J Int Med Res. 1989;17:87-92.

Fusco BM, Alessandri M. Analgesic effect of capsaicin in idiopathic trigeminal neuralgia. Anesth Analg. 1992;74:375-377.

Epstein JB, Marcoe JH. Topical application of capsaicin of treatment of oral neuropathic pain and trigeminal neuralgia. Oral Surg Oral Med Oral Pathol. 1994;77:135-140.

Fromm GH, Terrence CF, Chattha AS. Baclofen in the treatment of trigeminal neuralgia: double-blind study and long-term follow-up. Ann Neurol. 1984;15:240-244.

Fromm GH, Terrence CF. Comparison of L-baclofen and racemic baclofen in trigeminal neuralgia. Neurology. 1987;37:1725-1728.

Fromm GH, Aumentado D, Terrence CF. A clinical and experimental investigation of the effects of tizanidine in trigeminal neuralgia. Pain. 1993;53:265-271.

McCleane G. 200 mg daily of lamotrigine has no analgesic effect in neuropathic pain: a randomised, double-blind, placebo-controlled trial. Pain. 1999;83:105-107.

Serpell MG. Gabapentin in neuropathic pain syndromes: a randomised, double-blind, placebo controlled trial. Pain. 2002;99:557-566.

Keuter EJ. Treatment of trigeminal neuralgia with tegretol. Psychiatr Neurol Neurochir. 1966;69:439-451.

Parekh S, Shah K, Kotdawalla H. Baclofen in carbamazepine resistent trigeminal neuralgia - A double blind clinical trial. Cephalalgia. 1989;9:392-393.

Parmar BS, Shah KH, Gandhi IC. Baclofen in trigeminal neuralgia-a clinical trial. Indian J Dent Res. 1989;1:109-113.

Guerrero R, Escobar A, Caballero G. Tratamiento de la neuralgia del trigémino con gabapentin; correlación experimental. Trib Med (Bogotá). 1998;98:195-203.

Campbell FG, Graham JG, Zilkha KJ. Clinical trial of carbazepine (tegretol) in trigeminal neuralgia. J Neurol Neurosurg Psychiatry. 1966;29:265-267.

Rockliff BW, Davis EH. Controlled sequential trials of carbamazepine in trigeminal neuralgia. Arch Neurol. 1966;15:129-136.

Dalessio DJ. Medical treatment of tic douloureux. J Chronic Dis. 1966;19:1043-1048.

Killian JM, Fromm GH. Carbamazepine in the treatment of neuralgia. Use of side effects. Arch Neurol. 1968;19:129-136.

Nicol CF. A four year double-blind study of tegretol in facial pain. Headache. 1969;9:54-57.

Sturman RH, O´Brien FH. Non-surgical treatment of tic douloureux with carbamazepine (G32883). Headache. 1969;9:88-91.

Gilron I, Booher SL, Rowan JS. Topiramate in trigeminal neuralgia: a randomized, placebo-controlled multiple crossover pilot study. Clin Neuropharmacol. 2001;24:109-112.

Kondziolka D, Lemley T, Kestle JR. The effect of single-application topical ophthalmic anesthesia in patients with trigeminal neuralgia. A randomized double-blind placebo-controlled trial. J Neurosurg. 1994;80:993-997.

Gilron I, Booher SL, Rowan MS. A randomized, controlled trial of high-dose dextromethorphan in facial neuralgias. Neurology. 2000;55:964-971.

Vilming ST, Lyberg T, Lataste X. Tizanidine in the management of trigeminal neuralgia. Cephalalgia. 1986;6:181-182.

Lindstrom P, Lindblom U. The analgesic effect of tocainide in trigeminal neuralgia. Pain. 1987;28:45-50.

Lechin F, van der Dijs B, Lechin ME. Pimozide therapy for trigeminal neuralgia. Arch Neurol. 1989;46:960-963.

Wiffen P, Collins S, McQuay H. Anticonvulsant Drugs for Acute and Chronic Pain. A Biblioteca de Cochrane. 2003.

Sindrup SH, Jensen TS. Efficacy of farmacological treatments of neuropathic pain: an update and effect related to mechanism of drug action. Pain. 1999;83:389-400.

McQuay H, Carroll D, Jadad AR. Anticonvulsant drugs for management of pain: a systematic review. BMJ. 1995;311:1047-1052.

Jensen TS. Anticonvulsants in neuropathic pain: rationale and clinical evidence. Eur J Pain. 2002;6:61-68.

Sindrup SH, Jensen TS. Pharmacotherapy of trigeminal neuralgia. Clin J Pain. 2002;18:22-27.

Tratamento famacológico da neuralgia do trigêmeo: revisão sistemática e metanálise

Pharmacological treatment of trigeminal neuralgia: systematic review and metanalysis

Túlio César Azevedo Alves; Giselli Santos Azevedo; Emannuela Santiago de Carvalho

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