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Symptomatic Treatment of Neuropathic Pain: A Focus on the Role of Anticonvulsants

  • Authors: Faculty: Ahmad Beydoun, MD
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Target Audience and Goal Statement

This continuing medical education activity is intended for neurologists and pain specialists who diagnose and treat patients with neuropathic pain.

Neuropathic pain is defined as pain initiated by a primary lesion or dysfunction of the nervous system and can present a major therapeutic challenge to clinicians. In general, the elderly community and patients dealing with chronic illnesses are at an increased risk for developing this disorder. Recognized types of neuropathic pain include trigeminal neuralgia, peripheral neuropathies (i.e., diabetic, uremic, and AIDS-related), and post-herpetic and entrapment neuropathies. Antidepressants, opioid and analgesic medications, and early anticonvulsants have traditionally been used with varying levels of success and have been limited primarily by their side-effect profiles. Ion channel blockers and agents capable of influencing neurotransmitter action constitute the focus of modern treatment strategies. Newer anticonvulsants have shown significant improvements in efficacy and tolerability in early trials, although further studies are still required.

This complimentary continuing education activity will discuss the epidemiology and pathophysiology of neuropathic pain and review recent clinical trials that support the efficacy of newer anticonvulsant drugs in its management.

Upon completion of this educational activity, participants will be able to:

  1. Define the classification and clinical manifestations of neuropathic pain

  2. Describe the pathophysiology of neuropathic pain

  3. Explain the mechanism of action of anticonvulsant drugs in the management of this pain type

  4. Review key clinical trial data and current evidence-based therapeutic options

  5. Develop and effectively utilize a treatment algorithm that deals with appropriate drug selection and titration in treating the various neuropathic pain syndromes


  • Ahmad Beydoun, MD

    Associate Professor of Neurology, Director, Epilepsy Program and Investigational, Antiepileptic Drugs Trial, University of Michigan Health Systems, Ann Arbor, Michigan


    Disclosure: Grant/Research Support: Parke-Davis, Novartis Pharmaceuticals Corporation, Abbott Laboratories, Glaxo Wellcome, Inc.
    Speakers Bureau: Parke-Davis, Novartis Pharmaceuticals Corporation, Abbott Laboratories, Glaxo Wellcome, Inc.

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  • The Strategic Institute for Continuing Health Care Education is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

    The Strategic Institute for Continuing Health Care Education designates this continuing medical education activity for a maximum of 1 hour in category 1 credit toward the AMA Physician's Recognition Award. Each physician should claim only those hours of credit that he/she actually spent in the educational activity.

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Symptomatic Treatment of Neuropathic Pain: A Focus on the Role of Anticonvulsants: Clinical Features of Neuropathic Pain Syndromes


Clinical Features of Neuropathic Pain Syndromes

  • One of the important neuralgias is trigeminal neuralgia which is characterized by affecting predominantly the second [V2] and third [V3] distribution of the trigeminal nerve. It is most common in middle-aged women. Frequently there is an associated trigger point: touching specific parts of the face, chewing [or] a light breeze touching the face can result in pain characterized by a lancinating shooting, electric-like sensation that can last anywhere from a few seconds to a couple of minutes and recur multiple times daily. There is a strong association [between trigeminal neuralgia and] multiple sclerosis and, in order to make that diagnosis, the neurologic examination including a detailed examination of the trigeminal nerve [should be normal].

  • Trigeminal Neuralgia


    Trigeminal Neuralgia

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  • The next neuropathy that has been extensively evaluated in clinical trials is diabetic neuropathy. It is estimated that 10% of patients already have a neuropathy at the time the diagnosis of diabetes is made. Fifty percent will go on to develop a neuropathy during their lifetime. Not all neuropathies are painful, but about a third of them are associated with pain. The pain is commonly described as being superficial, predominantly burning, affecting the feet and hand, [and is] associated with allodynia, the perception of pain following an innocuous stimulus. But you can also have a shooting electric-like component of pain as well [as] a musculoskeletal cramping and aching component.

  • Diabetic Neuropathy


    Diabetic Neuropathy

    (Enlarge Slide)
  • The [third] condition that was evaluated in clinical trials is post-herpetic neuralgia. This condition is defined as pain lasting for a month or more following crusting or healing of the characteristic zoster rash. It occurs in 9 to 14% of patients following a bout of acute zoster. This condition is very much age-dependent. As you can see, 50% of patients age 60 years of age or more go on to develop post-herpetic neuralgia as well as 75% of those 70 years of age or older.

    It is slightly more common in women, probably a reflection of the fact that women tend to outlive us. And it has a predilection for the thoracic dermatomes as well as the ophthalmic division, the V1 distribution, of the trigeminal nerve. Whereas trigeminal neuralgia affects V2 and V3, post-herpetic neuralgia predominantly affects V1. The pain can be excruciating, characterized by steady burning, aching pain, as well as a paroxysmal lancinating, electric-like component.

  • Post-Herpetic Neuralgia


    Post-Herpetic Neuralgia

    (Enlarge Slide)
  • This reviews the various classes of drugs that have been reported to have efficacy in the treatment of neuropathic pain. We typically tend to use antidepressants, anticonvulsants and antiarrhythmics, drugs such as mexiletine, topical formulations - capsaicin [and] lidocaine cream - and finally the opioids.

  • Pharmacologic Management of Neuropathic Pain


    Pharmacologic Management of Neuropathic Pain

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  • It's important at the onset to mention that there are a number of clinical features associated with painful neuropathies that need to be treated independently from the pain per se. Many patients with painful neuropathy tend to have insomnia because the pain is more severe at night and interferes with their ability to go to sleep. You can also have reactive anxiety and depression. And depression is extremely important because, if the patient is depressed, you can pretty much try every combination of drugs known in the books and it's unlikely that the patient will respond unless and until the depression is treated.

    And obviously patients with chronic neuropathic pain have an overall decrease in their quality of life.

  • Clinical Features Associated With Painful Neuropathy


    Clinical Features Associated With Painful Neuropathy

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