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4.7.3 Trigeminal neuralgia, antimigraine drugs, prophylaxis of migraine

4.7.3 Neuropathic Pain

Amitriptyline tablets, liquid
Carbamazepine tablets, liquid
Capsaicin 0.075% (Axsain) cream
Lidocaine infusion (Specialist use only)
Lidocaine Plasters (see note)
Phenytoin capsules
Gabapentin - see note
Pregabalin - see note
Ketamine (RED DRUG):
  • Neuropathic pain is an unlicensed indication

  • Palliative care use only according to guidelines

  • Oral solution 50mg/5ml (stored in fridge)

Pregablin capsules - only after amitriptyline and gabapentin have failed at optimised doses (initiation by specialist pain consultants)

Notes:

1. Gabapentin and pregabalin have been the subject of a NHSE advice bulletin. Whilst the potential benefits of these agents in epilepsy and neuropathic pain management are well recognised, what is less well understood is that they can lead to dependence and may be misused or diverted. Caution is especially required in patients with a history of substance, alcohol, or drug misuse. Prescribers should make a careful assessment to balance these potential benefits and risks. If dependence is suspected, and planned withdrawal is considered appropriate, the drug should be withdrawn by slow tapering. Guidance is given in the document.

2. After several months pain free an attempt should be made to withdraw treatment gradually over several weeks (natural remission may occur).

3. Pregablin is for use in Pain Clinic only and should only be prescribed for patients who have received maximal doses of Gabapentin, or who are intolerant of high doses, but continue to show demonstrable benefit; it should not be used as an alternative where Gabapentin has failed to show benefit.

4. Lidocaine plasters have been included in the NHS England document published in July 2017: Items which should not routinely be prescribed in primary care: a consultation on guidance for CCGs. Lidocaine plasters were classified as ‘an item of low clinical effectiveness, where there is a lack of robust evidence of clinical effectiveness or there are significant safety concerns’. Lidocaine plasters are only approved for the following conditions

  • Pain Clinic uses only for post Herpetic Neuralgia
  • Management of rib fractures following blunt force trauma. Lidocaine plasters are only recommended for patients who are unable to have an epidural and are under the care of the acute pain team. These should only be used for a maximum of five days and patients should not be discharged on them. 

 

 

4.7.4 Antimigraine drugs

Sumatriptan tablets, injection, nasal spray
Zolmitriptan dispersible tablets
Frovatriptan tablets - third line use for patients whose migraine frequently returns (neurologist initiation only)
Aspirin + metoclopramide 325/5 (Migravess) soluble tablets
Paracetamol + metoclopramide 500/5 (Paramax) sachets
Migraleve tablets

 

4.7.4.2 Prophylaxis of Migraine

Amitriptyline tablets, syrup
Botulinum toxin type A (Botox) injection (specialist use only – migraine clinic)
Pizotifen tablets
Propranolol tablets, MR capsules

Prophylaxis is recommended if attacks are frequent (i.e. one or more per fortnight).

See NICE TA 260: Botulinum toxin type A is recommended as an option for the prophylaxis of headaches in adults with chronic migraine.

For link to BNF section: 4.7 Analgesics