Anticonvulsants in Trigeminal Neuralgia: A Class-Based Systematic Review

Abstract

Introduction: Trigeminal Neuralgia (TN) is a chronic neuropathic condition characterized by sudden, severe facial pain. Anticonvulsants are the cornerstone of pharmacological management, yet comparative evidence based on pharmacological class still remains scarce. This systematic review aimed to evaluate the efficacy and safety of anticonvulsants in TN, stratified by their mechanism of action. Methods: A systematic search of PubMed, Scopus and Web of Science was conducted on October 11, 2024, following PRISMA 2020 guidelines. Studies were included if they investigated the use of anticonvulsants or opioids in human patients with TN. Only studies published in English since 2000 were considered. Risk of bias was assessed using the Cochrane RoB 2 tool, the ROBINS-I tool and the ROBINS-E tool, according to the study design. Data were synthesized by drug class: sodium channel inhibitors, calcium channel inhibitors, synaptic vesicle modulators, and glutamate receptor antagonists. Results: Out of 650 initial records, 12 studies met the eligibility criteria. Sodium channel inhibitors showed high efficacy but frequent adverse effects, particularly hyponatremia and central nervous system symptoms. Calcium channel modulators offered a more favorable safety profile. Combination therapies showed additive benefits in patients with multiple sclerosis. Levetiracetam and topiramate were moderately effective and well tolerated. No eligible studies assessed opioid efficacy in acute TN. Conclusion: Anticonvulsants remain the primary treatment for TN, with sodium channel blockers offering robust efficacy and other agents providing better tolerability. Evidence supports a mechanism-based approach to drug selection. High-quality randomized studies are needed to confirm these findings and guide future clinical decisions.