Re: atypical facial pain

Posted By CCF Neuro[P] MD, RPS on September 30, 1998 at 18:07:11:

In Reply to: Re: atypical facial pain posted by CCF Neurology MD - AY on September 30, 1998 at 15:29:21:






my 11 year old daughter has suffered from atypical facial pain for the last 5 years.  She had mastioditis and isolated sphenoid sinusitis, and still has severe pain on the laft side of her face, eye and head.  She is currently on 900 mg of tegretol and 20mg of paxil/ day and has had relief of the symptoms.  She had an infection last week and it flared the pain again.  now the neurologist wants to increase the tegretol to 1000 mg/day.  how long can a child remain on tegretol at these levels and are there any other alternatives?  Is there any research as to what may cause a flare of the pain so we can help her to avoid those situations if possible?  Thank You.






: Thanks for your question.  The symptoms described in your message are
suggestive of a trigeminal neuralgia, that is a localized pain the innervation
territory of the fifth cranial nerve, or trigeminal nerve.  Trigeminal
neuralgia can often be associated with a Herpes Simplex viral infection
(which can be completely asymptomatic, except for the facial pain).  Often,
even with the resolution of pain symptoms, viral particles will remain
in the trigeminal ganglion.  An incidental external factor, such as other
viral infection or a bout of fever can trigger a reccurrence of the trigeminal
pain.  Unfortunately, there are no clear preventive measures for such reccurrences.
The planned increase in Tegretol dosage is below levels where one would see
significant side effects.  As you are probably aware, tegretol is very often
used in epilepsy, and assuming that your daughter is of normal stature and
weight, her dosage of tegretol is NOT unusually high.  Another anti-epileptic
medication also used in neurogenic pain is Neurontin.
I hope this information is helpful.  Best of luck.
This information is provided for general medical education purposes only.
Please consult your doctor regarding diagnostic and treatment options.
Dear Wendy:
My adult collegue asked me to also answer your question.  I am a pediatric neurologist and I would agree with everything that he has stated.  Just a question, why is your daughter taking Paxil?  Is she depressed or does she have OCD?  I do not think that using tegratol for trigeminal neuraglia is wrong.  Most of us would use a good dose that has benefit (stops the pain)until side effects of the medication start to happen.  These would be nystagmus, ataxia, nausea and vomiting, gastric upset, drowsiness etc.  The problem with tegratol is its interaction with other medications and the need for lab to check decrease in white cells and liver function tests.  For these reasons I would probably start with neurontin and would see if it would stop the pain.  There are less interactions and less side effects.  As this condition might reoccur, it might be important to note that when your daughter starts to have her menses (I know that this is a far off thought but believe me it will occur) the use of neurontin might be a better choice if she starts to take birth control pills or has acne and needs to take acne medications (acne and menses have a correlation).  Just a thought.  This may be my choice but I could not fault your physician for his choice either.  By the way, if someone wants to start steroids.  Most of the studies come from the adult world and are flawed.  Of the good studies, it may be that acylovir with steroids might be a treatment, but I would let the data accumulate before I would start doing something like that.  The data would suggest that treatment before 21 days after the initial symptoms works best with this treatment.  But let the data filter down to children first.  Good luck, and follow what your doctor has to say, he or she knows your daughter best.
Sincerely,
CCF Neuro:Pediatrics MD, RPS