cbd oil for atypical trigeminal neuralgia

CBD Oil for Trigeminal Neuralgia: Is Cannabis a Viable Approach?

Neuropathic pain has many faces, one of which includes trigeminal neuralgia. This condition affects the nerves that transmit sensation from the face to the brain, causing severe discomfort comparable to an electric shock. The TN pain can be triggered by the slightest movement or touch anywhere on the face, commonly affecting the lips, gums, jaw, and cheeks.

People with trigeminal neuralgia usually suffer from flare-ups affecting one side of the face at a time. Although short-lived at the beginning, the episodes of burning sensation may become chronic, lasting for weeks or longer.

CBD has been mentioned by researchers as a potentially viable remedy for pain that is difficult to treat. Trigeminal neuralgia fits within this definition like a glove.

Today we’ll elaborate on the problem of TN pain and how to treat it with natural resources.

CBD Oil for Trigeminal Neuralgia: Highlights

  • Trigeminal Neuralgia (TN) develops as a result of the damage caused to the trigeminal nerve, causing severe pain on the face.
  • CBD’s interaction with the endocannabinoid system (ECS) may provide relief from neuropathic pain by mitigating the pain signals. According to a study published in Pharmacological Reviews, CBD strengthens nerve impulses in the ECS receptors, producing analgesic effects (1).
  • A review of studies concluded that CBD might be useful in reducing neuropathic pain and sensitivity to pain signals (hyperalgesia) (2).
  • Researchers have reported that hypertension (high blood pressure) increases the risk of trigeminal neuralgia. In a 2017 study, subjects who received CBD showed reduced resting blood pressure (3).
  • More clinical studies on humans are needed to support the preclinical findings of CBD’s benefits for people with trigeminal neuralgia.

Why People Are Turning to CBD for Trigeminal Neuralgia?

The dysfunction of the trigeminal nerve can have debilitating consequences for the sufferers. It causes severe pain on the face that occurs upon even the slightest movement, such as touching, scratching, or rubbing. The condition may also cause muscle spasms and burning sensations on top of the shock-like pain.

The treatment of trigeminal neuralgia usually involves anticonvulsant medications, antispasmodic agents, surgery, and other procedures involving the trigeminal nerve. Antiepileptic drugs, such as carbamazepine and gabapentin have been used with some success, although they lack efficacy and intolerability with prolonged use.

This is where CBD starts to shine.

Studies on CBD and Trigeminal Neuralgia

CBD is an acknowledged antiepileptic treatment. Its anticonvulsant and neuroprotective properties have been recently posted in a study from the journal Molecules. These actions might be useful in reducing muscle spasms in TN patients (4).

Although studies haven’t analyzed the efficacy of CBD on spasms caused by TN, there is evidence that CBD may have significant benefits for treating chronic pain caused by the condition.

One review has pointed to CBD as the potential reliever of hyperalgesia (pain sensitivity). The review mentioned that CBD can effectively block the pain pathway’s neural transmission. The authors also highlighted the nociceptive effects of cannabinoids, describing them as the potential therapeutic approach to the management of TN pain.

The painkilling and anti-hyperalgesia effects of CBD were supported by an animal study published in the Journal of Experimental Medicine. The study suggested that CBD reduced pain and inflammation caused by neuropathy.

Neuropathy stems from dysfunction or damage in the nerves that may trigger pain, tingling sensation, muscle weakness, and numbness.

On top of the above findings, the authors of the study added that CBD was able to curb hyperalgesia in mice models. There was a conclusion that CBD reduced persistent inflammation and neuropathic pain.

Another paper from the European Journal of Pharmacology demonstrated remarkable anti-inflammatory and immunomodulatory effects of CBD. Cannabidiol was administered to rats with induced sciatic nerve pain. The research team found that CBD treatment lowered inflammation and reduced hyperalgesia (5).

Experts hypothesize that trigeminal nerve pain can be caused by the contraction of blood vessels in the trigeminal nerve. This contraction damages the trigeminal protective tissue. Furthermore, researchers noticed that high blood pressure contributes to the development of trigeminal neuralgia (6).

A 2017 preclinical study found that CBD has benefits for the cardiovascular system. The authors reported that healthy individuals (age 21–29) with hypertension caused by a stressful event showed lower blood pressure after taking CBD (7).

Since the majority of the studies on CBD and trigeminal neuralgia have been conducted on animal models and preclinical human samples, longitudinal clinical studies are needed to further prove CBD’s ability to treat the condition.

How Does CBD Oil Work for Trigeminal Neuralgia?

The benefits of CBD for trigeminal neuralgia are attributed to the human endocannabinoid system (ECS). The ECS is the major regulatory network engaged in maintaining homeostasis in the central nervous system, peripheral nervous system, immune system, and organs. The ECS contains receptors that are found throughout the body, including CB1, CB2, and glycine receptors.

Studies have found that the modulation of the ECS might promote the healthy functioning of biological processes, providing a wide range of therapeutic benefits.

For example, a study published in the Journal of Experimental Medicine found that modulating the ECS translates into therapeutic effects for pain management. The authors also mentioned that glycine receptors in the central nervous system are important targets for reducing neuropathic pain. According to the study, cannabinoids such as THC and CBD might enhance the activity of the glycine receptors, resulting in analgesic effects.

Glycine receptors are ion channels that control the transmission of pain signals from the nerve to the brain.

The study found that oral CBD products resulted in a binding glycine activity that lowered neuropathic pain and hyperalgesia in animal models.

The Pros and Cons of CBD Oil for Trigeminal Neuralgia

The Pros

  • Numerous studies have demonstrated the therapeutic potential of CBD in pain management thanks to its ability to modulate receptors in the ECS.
  • Researchers agree that CBD might strengthen nerve impulses and increase pain resistance.
  • Animal studies have found that oral CBD solutions might be useful in lowering one’s sensitivity to pain.
  • CBD can reduce blood pressure in healthy volunteers, indirectly reducing the risk of trigeminal neuralgia
  • Many international medical organizations agree that CBD is well-tolerated in humans and has a high safety profile.

The Cons

  • There is not enough clinical evidence to support CBD’s efficacy in treating trigeminal neuralgia
  • CBD has a few mild side effects, including dry mouth, reduced appetite, drowsiness, and CBD-induced drug interactions
  • According to one animal study, extremely high doses of CBD can cause liver toxicity. However, these results haven’t been confirmed on human subjects.

CBD vs. Alternative Treatments for Trigeminal Neuralgia

There are limited options when it comes to alternative treatments for trigeminal neuralgia. The alternative anticonvulsants, except for CBD, aren’t supported by scientific studies. Recently, acupuncture has been touted for its effectiveness in treating neuropathic pain. There are lots of reports from TN patients who claim to have successfully treated TN with acupuncture.

Acupuncture is part of traditional Chinese medicine that uses tiny needles to balance the energy flow within the body. Studies also mention acupuncture’s ability to support homeostasis in the ECS. However, direct studies are needed to find out how acupuncture affects cannabinoid receptors.

One study from Frontiers of Molecular Neuroscience has found that electroacupuncture increased receptor activity in the rat models of osteoarthritis, resulting in reduced pain. Electroacupuncture is performed by sending electric signals through the microneedles (8).

Weird as it may sound, CBD has similar effects on the body to electroacupuncture. One study has found that the modulation of adenosine receptors resulted in mitigated pain and lower inflammation in mice after they took CBD (9).

Vitamin B12 is another alternative for trigeminal neuralgia. Research shows that vitamin B12 has painkilling properties that may aid patients in managing neuropathic pain.

Several clinical studies have reported positive results after treating patients with methylcobalamin, a form of B12. These studies examined patients with different types of neuropathy, such as trigeminal neuralgia and diabetic neuropathy (10).

How to Take CBD Oil for Trigeminal Neuralgia?

CBD comes in different forms, concentrations, and formulas. It may be taken orally in the forms of capsules or gummies, or sublingually as oil drops. Some people vape CBD, while others use it topically for localized relief. The choice of the product boils down to your individual situation.

CBD oil is the most common format. It contains a hemp extract infused into an inert oil, such as MCT oil or olive oil. CBD oil comes with a dropper for easier and more accurate dosing. You just squeeze the preferred amount using the dropper, place a few drops under your tongue, and wait for up to 60 minutes until it absorbs through tiny capillaries in your mouth. The calming effects of CBD should be felt within 15–20 minutes.

If you don’t like the taste of CBD oil, capsules and edibles are a good alternative. CBD capsules are available in the form of soft gels, providing a fixed dose of CBD per serving. They are better suited for busy people who take their CBD on the go. Since the CBD needs to pass through the digestive system before absorbing into the bloodstream, capsules have a delayed onset, usually around 40–90 minutes depending on your metabolism and whether or not you’re taking CBD oil on an empty stomach.

Edibles work in a similar fashion, but they are made with fun flavors that make the whole experience more enjoyable. The most popular forms of CBD edibles are gummies and honey sticks.

If you’re looking for the most effective way to deliver CBD to your system, CBD vape pens will be your best bet. Vaporized CBD gets into the bloodstream through the lung tissue, producing its effects within minutes after inhalation. CBD vapes also offer the highest bioavailability of all consumption methods, ensuring that up to 56% of the ingested substance is absorbed.

Finally, you may try a topical formulation, such as CBD creams for localized relief. Topicals work best for flare-ups because they address inflammation by interacting with the CB2 receptors in the skin’s endocannabinoid system. The absorption rate and duration of CBD topicals vary between products; you may need to reapply the dose after a few hours for consistent results.

Dosage of CBD Oil for Trigeminal Neuralgia

There are not enough clinical trials to determine the effective CBD dosage for specific health conditions.

According to a study published in the British Journal of Pharmacology, a low dose may vary from less than 1 to 50 milligrams per one kilogram per day. Everybody is different, and factors like your age, gender, metabolism, weight, overall health, and prior experience with CBD will affect your optimal dosage range.

It will take some experimentation until you find out what works for you. It is recommended to start with a low dose, say, 10 mg of CBD once or twice daily for one week — and observe the results. If you don’t feel any pain relief after that time, add another 10 mg to the dosage and continue for another week. Once you’ve found an effective dose, you can stick to it — people don’t build a tolerance to CBD.

If you’re thinking about adding CBD oil to your trigeminal neuralgia treatment, consult a holistic doctor experienced in CBD and cannabis therapies in general. Doing so will help you determine the right dosage range for your condition on top of avoiding potential negative CBD-induced drug interactions.

Summarizing the use of CBD for Trigeminal Neuralgia

Studies support CBD’s therapeutic effects in a range of painful conditions, including neuropathic pain. CBD modulates the activity of the cannabinoid receptors in the ECS, mitigating pain signals and reducing inflammation throughout the body. Moreover, CBD has been found to reduce blood pressure when administered under stressful conditions. All these effects can have a positive impact on the symptoms of trigeminal neuralgia. CBD is also an acknowledged anticonvulsant and neuroprotectant, so it can prevent further damage to the trigeminal nerve.

More direct clinical trials are needed to prove CBD’s efficacy specifically in alleviating TN pain. However, current findings, as well as reports from patients, are very encouraging.

Do you take CBD for trigeminal nerve pain? What products work best for you? Share your thoughts in the comment section!

Literature:

  1. Pacher, Pál et al. “The endocannabinoid system as an emerging target of pharmacotherapy.” Pharmacological reviews vol. 58,3 (2006): 389-462. doi:10.1124/pr.58.3.2
  2. Liang, Ying-Ching et al. “Therapeutic potential of cannabinoids in trigeminal neuralgia.” Current drug targets. CNS and neurological disorders vol. 3,6 (2004): 507-14. doi:10.2174/1568007043336833
  3. Turner, C L et al. “Measurement of pulse pressure profiles in patients with trigeminal neuralgia.” Journal of neurology, neurosurgery, and psychiatry vol. 74,4 (2003): 533-5. doi:10.1136/jnnp.74.4.533
  4. The U.S. Food and Drug Administration. The FDA Approves First Drug Comprised of Cannabidiol.
  5. Costa, Barbara et al. “The non-psychoactive cannabis constituent cannabidiol is an orally effective therapeutic agent in rat chronic inflammatory and neuropathic pain.” European journal of pharmacology vol. 556,1-3 (2007): 75-83. doi:10.1016/j.ejphar.2006.11.006
  6. Trigeminal Neuralgia Overview.
  7. Jadoon, Khalid A et al. “A single dose of cannabidiol reduces blood pressure in healthy volunteers in a randomized crossover study.” JCI insight vol. 2,12 e93760. 15 Jun. 2017, doi:10.1172/jci.insight.93760
  8. Yuan, Xiao-Cui et al. “Electroacupuncture Potentiates Cannabinoid Receptor-Mediated Descending Inhibitory Control in a Mouse Model of Knee Osteoarthritis.” Frontiers in molecular neuroscience vol. 11 112. 6 Apr. 2018, doi:10.3389/fnmol.2018.00112
  9. Russo, Ethan B. “Cannabinoids in the management of difficult to treat pain.” Therapeutics and clinical risk management vol. 4,1 (2008): 245-59. doi:10.2147/term.s1928
  10. Zhang, Ming et al. “Methylcobalamin: a potential vitamin of pain killer.” Neural plasticity vol. 2013 (2013): 424651. doi:10.1155/2013/424651
Livvy Ashton

Livvy is a registered nurse (RN) and board-certified nurse midwife (CNM) in the state of New Jersey. After giving birth to her newborn daughter, Livvy stepped down from her full-time position at the Children’s Hospital of New Jersey. This gave her the opportunity to spend more time writing articles on all topics related to pregnancy and prenatal care.

Leave a comment Cancel reply

Your email address will not be published. Required fields are marked *

Save my name, email, and website in this browser for the next time I comment.

Does CBD Oil Help Patients with Trigeminal Neuralgia? [Exploring the Science]

Trigeminal neuralgia is a painful condition affecting the nerves of the face. It can make everyday activities such as eating and talking unbearable and have a significant impact on a person’s life.

Furthermore, traditional painkillers often don’t help numb the agony of trigeminal neuralgia. Doctors sometimes prescribe anticonvulsant drugs, which can ease the pain but come with a long list of potential side effects. This situation has left many patients wondering whether natural remedies like CBD oil could help.

So, does CBD oil help patients with trigeminal neuralgia? Keep reading to find out.

What Is Trigeminal Neuralgia?

Trigeminal neuralgia is sometimes called tic douloureux. It is a condition that affects the fifth cranial (trigeminal) nerve. This nerve is one of 12 pairs that attach directly to the brain, and it connects to the face with three branches. These branches supply the:

  • Upper, middle, and lower regions of the face
  • Forehead and scalp
  • Cheeks and upper jaw
  • Lower jaw

Trigeminal neuralgia occurs when this nerve becomes compressed, leading to facial pain. The level of discomfort could interfere with everyday activities and severely reduce one’s quality of life.

Therefore, many patients with trigeminal neuralgia also suffer from depression, sleep problems, and anxiety.

Trigeminal Neuralgia Symptoms

The main symptom of trigeminal neuralgia is severe facial pain. This pain is sometimes unpredictable and arrives suddenly with little warning. Most people describe it as a shooting pain, which can feel like an electric shock in the jaw, teeth, and gums.

These symptoms usually affect just one side of the face. Occasionally, both sides are affected, but usually not at the same time.

Trigeminal neuralgia attacks can last for anywhere between a few seconds and two minutes.

In severe cases, they may occur hundreds of times each day. Bouts can last for days, weeks, or months at a time. At this point, patients may experience a symptom-free period (remission).

However, over time, these periods of remission can become shorter. Eventually, a patient may be left with a continuous throbbing, aching, or burning sensation, even between attacks.

Unsurprisingly, trigeminal neuralgia often causes other symptoms, such as weight loss if a patient is unable to eat properly.

What Causes Trigeminal Neuralgia?

Trigeminal neuralgia is the result of pressure on the trigeminal nerve. In approximately 95% of cases, the condition is due to a blood vessel pressing on the nerve. This is known as primary trigeminal neuralgia.

In other cases, the pressure could come from a cyst, tumor, or cluster of malformed blood vessels. It may also be related to multiple sclerosis or due to an injury or surgical damage. These cases are called secondary trigeminal neuralgia. Nobody is sure why some people develop trigeminal neuralgia and not others. However, it is more prevalent in women and those over 50 years of age.

Trigeminal Neuralgia Triggers

Even the slightest movement or touch can trigger an episode of trigeminal neuralgia. However, in some cases, the symptoms of trigeminal neuralgia can flare up without any apparent cause.

Some common triggers include:

  • Talking
  • Eating
  • Washing the face
  • Brushing the teeth
  • Shaving
  • Applying makeup
  • Kissing
  • Cold drafts/air conditioning
  • Head movements
  • Vibrations, including walking or traveling by car

Although it is impossible to avoid all of these triggers, patients can help themselves in some situations. Some find that wrapping a scarf around their face and avoiding drafts provide some relief. Drinking through a straw and liquidizing meals are also options, although they are not always practical.

Common Trigeminal Neuralgia Treatments (Not CBD Oil)

Regular painkillers have little effect on trigeminal neuralgia. Therefore, most doctors prescribe anticonvulsant drugs to help manage the condition. Although these medications are designed to treat epilepsy, they have the effect of slowing down nerve signals and relieving pain.

One of the most common examples is carbamazepine (Tegretol). Unfortunately, this medicine comes with a list of unpleasant side effects, including:

  • Drowsiness
  • Confusion
  • Poor concentration
  • Nausea
  • Double vision

Furthermore, this drug can become less effective over time, leaving patients searching for an alternative.

Other treatments include surgery and percutaneous procedures. The latter involves intentionally damaging the nerve to block its signals. Therefore, it can leave patients with numbness or pins and needles on the affected side of the face.

Complementary approaches include acupuncture, biofeedback, and meditation to help with pain management. However, there is sparse clinical evidence to support the use of these techniques.

With such limited treatment options available, it’s unsurprising that many patients are dissatisfied. Therefore, many are wondering whether CBD oil can help trigeminal neuralgia. Let’s take a look.

CBD Oil for Trigeminal Neuralgia

Cannabidiol, also known as CBD, is now among the most popular natural health products in the world. It is one of the many active compounds found in cannabis plants.

Unlike THC, CBD does not cause intoxication. However, it does have a wide range of both physical and psychological effects. These effects are primarily due to CBD’s ability to interact with the body’s built-in endocannabinoid system (ECS).

The Endocannabinoid System and Pain

The ECS is a complex network of cell receptors called cannabinoid receptors and chemicals called endocannabinoids. When these components bind together, they trigger a variety of responses that help to maintain a state of homeostasis (balance).

The ECS runs throughout the entire body, including the brain and nervous system. It is involved in controlling mood, movement, memory, and pain.

Scientists are still working hard to determine the exact role of the ECS in pain management. However, it appears to interact with several of the body’s other systems, including the endorphin/enkephalin system. These are the body’s natural analgesics, and it is the system that opioids act upon to relieve pain.

The ECS also has a close connection with pain receptors known as TRPV1. These receptors work to detect both heat and pain. For example, they become active when someone eats spicy food, such as chili peppers. They send messages to the brain via nerve fibers and help to trigger a healing response.

How CBD Could Work for Pain Relief

CBD works by increasing the levels of natural endocannabinoids. In this way, it can enhance the activity of the ECS and aid patients with inflammation and pain. It also has neuroprotective effects, allowing it to potentially protect nerve cells from damage.

There are few studies specifically on CBD for trigeminal neuralgia. However, there is some evidence that it can benefit neuropathic pain. For example, this 2008 review, Cannabinoids in the Management of Difficult to Treat Pain, suggests that these compounds show ‘great promise’ in the treatment of neuropathy.

Research is ongoing, but hopefully, in the future, we will see substantial evidence regarding the efficacy of CBD for trigeminal neuralgia

CBD Oil for Anxiety and Depression Associated with Trigeminal Neuralgia

Due to its debilitating nature, many people with trigeminal neuralgia also suffer from depression, anxiety, and sleep issues. Fortunately, this is another area where CBD oil may help.

A 2014 study for CNS and Neurological Disorders Drug Targets found that CBD has both antidepressant and anti-anxiety properties.

Again, this is due to how the compound interacts with the ECS. It increases the circulating amounts of a specific endocannabinoid called anandamide. This chemical is often referred to as ‘the bliss molecule.’

CBD may also help to support healthy sleeping patterns, as this 2019 study for The Permanente Journal demonstrated. Of its 72 participants, 57 experienced reductions in anxiety scores while 48 experienced better sleep.

How to Take CBD Oil for Trigeminal Neuralgia

Those living in a state where medical marijuana is legal may wish to apply for a medical marijuana card. Several states list neuropathic pain as one of their qualifying conditions. Patients in these locations can benefit from more potent products containing THC alongside CBD.

Those who don’t live in a legal state can try a CBD oil that comes from hemp. Hemp contains less than 0.3% THC and is widely legal in the US.

The most popular way of taking hemp-derived CBD is via an oil. The preferred method of taking CBD oil is to place the oil under the tongue and hold for 60–90 seconds before swallowing. CBD is also available in many other forms, including capsules, edibles, vape products, and topicals.

Each of these forms has its pros and cons. For more information, check out our article CBD Therapy: Which Is Best for You?

One thing to consider when purchasing CBD oil for trigeminal neuralgia is whether the product is full-spectrum or an isolate. Full-spectrum products are potentially more effective since they contain a range of other cannabis compounds alongside CBD.

This is relevant because other cannabinoids, such as CBC and CBG, and some cannabis terpenes also have painkilling properties. Many experts believe that these chemicals work together synergistically to produce enhanced effects.

It is also essential to choose a CBD brand carefully. Some companies are selling inferior goods thanks to a lack of market regulation. Look for a brand that publishes third-party lab reports to confirm the cannabinoid content of their oils. It is also important to read plenty of reviews before buying.

Does CBD Oil Help with Trigeminal Neuralgia? Final Thoughts

Those who have pain due to trigeminal neuralgia may find CBD oil useful. Still, bear in mind that CBD may not be powerful enough to manage the condition by itself. However, it could potentially provide some additional relief alongside other treatment methods.

It should be noted that CBD can interact with many prescription and over-the-counter drugs and could increase the risk of adverse effects. Therefore, patients should consult a medical professional before taking CBD oil for trigeminal neuralgia. They will be able to monitor progress and adjust the amount consumed if necessary.

Topical Medications for Common Orofacial Pain Conditions

Orofacial pain disorders comprise those painful conditions that affect the masticatory and cervical musculature, temporomandibular joints, intraoral structures, and the occipital, temporal, orbital, and frontal regions of the head. The diversity of pain complaints in this region often requires multidisciplinary management. As a result, patients may seek out practitioners from several specialties within medicine and dentistry for assessment and treatment. Having a basic understanding of these conditions may help patients avoid unnecessary office visits or diagnostic tests, as well as inappropriate treatments.

Orofacial pain disorders may be categorized as neuropathic, neurovascular, and temporomandibular joint (TMJ). Some of the most commonly treated conditions in a typical orofacial pain clinic may include: myofascial pain, trigeminal neuropathy, migraine, tension-type headache, chronic daily headache, TMJ arthritis and internal derangements, and burning mouth syndrome. Topical medications offer one modality with the following potential benefits compared to systemic approaches: topicals bypass first-pass metabolism; reduce systemic adverse effects; reduce potential for drug-drug interactions; provide direct, local analgesia; and improve patient compliance. This article provides a review of the topical medications currently used to treat orofacial pain, including their mechanisms of action and evidence supporting them, and provides insight into two emerging approaches: cannibinoids and traumeel.

Neuropathic Pain

Defined as “pain caused by a lesion or dysfunction of the somatosensory nervous system,” 1 neuropathic pain is a chronic pain disorder resulting from injury to the nervous system. The injury may be to any site in the central nervous system (CNS) or the peripheral nervous system (PNS), and pain may vary in intensity. However, in many patients, the pain may be so severe that it impacts their quality of life and daily function.

Within the orofacial region, there are several diagnoses for neuropathic pain, including: trigeminal neuralgia, painful post-traumatic trigeminal neuropathy, burning mouth syndrome, post-herpetic neuralgia, trigeminal neuroma, and other neuropathies related to systemic diseases (eg, diabetes mellitus, cancer, drug-induced, HIV/AIDS-related). 2 Described below, trigeminal neuralgia, painful post-traumatic trigeminal neuropathy, and burning mouth syndrome are the more common types of neuropathies seen in orofacial pain and dental practices according to the authors’ practice and the literature.

Trigeminal Neuralgia

Trigeminal neuralgia is defined as a sudden, short-lived stabbing or electric shock-like pain affecting one or more of the branches of the trigeminal nerve (cranial nerve V). The characteristics of this disorder are so specific that the diagnosis is made by history alone, although brain imaging is sometimes necessary. Pain is paroxysmal, lasting from seconds to a few minutes. 3 Trigeminal neuralgia may mimic tooth pain, and some patients report an intraoral trigger zone. While first-line treatment involves oral, medical management with carbamazepine, topical medications may also be effective. Specifically, topicals, such as 20% benzocaine, capsaicin, or a compounded formula of anticonvulsants, tricyclic antidepressants, serotonin and norepinephrine reuptake inhibitors, may be applied over an intraoral trigger zone (see below for more detail).

Painful post-Traumatic Trigeminal Neuropathy

Painful post-Traumatic Trigeminal Neuropathy (PTTN) is the term coined by the International Headache Society to describe neuropathic pain resulting from trauma to the trigeminal nerve. 4 Historically, this type of pain has also been described as deafferentation pain, traumatic neuropathy, phantom tooth pain, and atypical odontalgia. 4 PTTN affects approximately 2 to 3% of patients. 5 Occurring intraorally, PTTN can be complex to diagnose and to treat. Usually, the pain is localized to the site of trauma, but the pain may move around the area as well.

The pathophysiology of PTTN involves both the peripheral and central nervous systems. Alterations to a damaged nerve may lead to the sprouting of neural fibers, causing increased nociception. These changes may be localized to the peripheral nerve and termed “peripherally sensitized.” However, if central nerves become affected, then the nerves may be considered “centrally sensitized.” PTTN results in normal sensory signals being perceived as painful. In a peripheral injury, there is upregulation of voltage-gated sodium (Nav1.3 and Nav1.8) and calcium (α2γ subunit) channels. In addition, there is often a down-regulation of potassium channels and a reduction in the threshold of heat sensitive channels. These changes may cause ectopic discharge, leading to increased release of glutamate and activation of the N-methyl-D-aspartate (NMDA) receptors located in the CNS. Furthermore, there is increased excitatory neurotransmitter release and decreased inhibitory neurotransmitter release, which facilitate the nociceptive response centrally. Sympathetic nervous system involvement may also be seen in neuropathic pain. 6,7 All of these can serve as potential targets for pain management.

Topical Options for Trigeminal Neuralgia & PTTN

Treatment for trigeminal neuropathic pain conditions such as PTTN or neuralgia may involve both topical and systemic medications. When the injury only involves the peripheral branches of the nerve, topical medications such as those described below may be effective. However, when there is central sensitization, systemic medications are required. These include the usual classes prescribed for other neuropathies, such as anticonvulsants, tricyclic anti-depressants, serotonin, and norepinephrine reuptake inhibitors, or opioids. 4,8

When there is an intraoral trigger zone for PPTN or trigeminal neuralgia, topical medications may be more effective due to their enhanced absorption via the oral mucosa versus the skin. Topical medications that have demonstrated significant pain relief in orofacial neuralgias and neuropathies include anesthetics, capsaicin, anticonvulsants, anti-inflammatories, α2-adrenergic agonists, and NMDA-receptor antagonists. 9,10 In some cases, a compounded formula including some or all of these agents may be beneficial, but these formulations require the expertise of a pharmacist.

First-line topical medication options for trigeminal neuropathies include a topical anesthetic and/or capsaicin. Common topical anesthetics include benzocaine and lidocaine. 9 (Editor’s Update: FDA issued a recall of super potent lidocaine HCl topical solution 4%, 50 mL on Oct 20, 2021). The mechanism of action of these anesthetics involves inhibition of sodium channels. In trigeminal neuropathies or neuralgias, a thin layer of the topical anesthetic may be applied over the intraoral trigger zone. Topical anesthetics are usually mixed with a methylcellulose paste (orobase) in order to be absorbed transmucosally. 9 This application may be repeated 4 to 6 times per day.

Clonidine: Clonidine is an α2-adrenergic agonist that provides potent analgesia. In neuropathic pain, α2 adrenoreceptors are upregulated and are sensitive to norepinephrine. Activation of α2 adrenoreceptors therefore inhibits the release of calcitonin gene-related peptide and glutamate, which play an integral role in nociception as neurotransmitters. Clonidine may be compounded into a cream and applied topically to provide pain relief. Systemic side effects include sedation and hypotension, 10 requiring close monitoring.

Lidocaine: While evidence for the use of topical medications to treat trigeminal neuropathic pain is limited, a small case series of 14 patients treated for extraoral, trigeminal neuropathic pain with 5% lidocaine plasters showed improvement in 12 of the 14 patients. 11 Two patients were able to stop their adjuvant medication completely, while nine were able to reduce their medication. The plaster (available in the United Kingdom) was comprised of 700 mg of lidocaine mixed with a polyethylene terephthalate backing. The topical was used 12 hours per day for 4 weeks.

Of note, randomized control trials examining other neuropathic pain conditions have shown benefit with local anesthetics as well. For example, a lidocaine 5% patch has been demonstrated to provide pain relief in post-herpetic neuralgia and other peripheral neuropathic conditions. 8 Adverse effects are minimal and include erythema and rash. Systemic absorption is also limited with the approved maximum dosing recommendations. 8 Lidocaine gel may also be effective in patients with post-herpetic neuralgia. However, in those with HIV-related neuropathy, it was not proven beneficial. 8

Capsaicin: Capsaicin is a component of chili peppers. It binds to the nociceptor, TRPV1, which is located on polymodal C-fibers. 12 Initially capsaicin works by increasing the production of inflammatory mediators, causing hyperalgesia. However, repeated application may cause prolonged activation of the TRPV1 receptor, rendering it dysfunctional. 13 Capsaicin is available at low concentrations in over-the-counter creams. Vickers, et al. trialed patients diagnosed with atypical odontalgia (now referred to as PTTN) with an application of 0.025% capsaicin for 3 minutes twice a day, after local anesthetic application to the painful site. After 4 weeks, the authors found that 19 of 30 patients reported pain relief. After 3 months, their level of pain relief was maintained. 14 Common adverse effects of capsaicin include nausea, dyspepsia, and initial increase in pain when applied topically. 13,15 Pain relief is dose dependent and may last for several weeks. 16 Capsaicin preparations at higher doses, such as the capsaicin patch 8%, have shown to be more efficacious than lower concentrations. 16 Unfortunately, treatment is challenged by low adherence to this medication due to its side effects, particularly the burning pain associated with application. 17

Compounded formulas: A large compounded formula may also be effective in managing neuropathic orofacial conditions by targeting different receptors involved in the pathophysiology of the disorder. In 2008, a retrospective study evaluated the treatment of various orofacial neuropathic conditions (deafferentation pain, traumatic neuroma, and trigeminal or glossopharyngeal neuralgia) with topical and/or systemic medication. The authors included 39 patients and found that those receiving treatment with topical therapy reported 40% pain reduction. The topical medication used was a compounded formula of:

  • carbamazepine 4% (a sodium channel blocker)
  • lidocaine 1%
  • ketoprofen 4% (a non-steroidal anti-inflammatory drug, or NSAID)
  • ketamine 4% (an NMDA-receptor antagonist)
  • gabapentin 4% (a calcium channel blocker).

These medications were mixed with anhydrous gels and bio-adhesive copolymers. 18 Another study involving rats undergoing intraorbital nerve injury showed improvement with topical application of pregabalin 5% or 10%, diclofenac 5% (an NSAID); or both pregabalin 5% (a calcium channel blocker) and diclofenac 5% for 4 days. 19

Burning Mouth Syndrome

Burning mouth syndrome (BMS) is a chronic, neuropathic pain condition affecting the tongue, hard palate, and oral mucosal membranes. It is described as a painful burning sensation over these tissues in the absence of any organic pathology. According to the International Headache Society, BMS is defined as “an intraoral burning or dysaesthetic sensation, recurring daily for more than 2 hours per day over more than 3 months, without clinically evident causative lesions.” 20

Topical therapies for BMS: While burning mouth syndrome may be challenging to manage, topical application of clonazepam has shown to provide pain relief. Clonazepam is a gamma-aminobutyric acid (GABA)-A agonist, which enhances the inhibitory action of this neurotransmitter. This acts on both peripheral and central receptors, thereby causing central serotonergic modulation and reduction of central neuronal hyperactivity. 21

Topical clonazepam may be applied through a swish-and-spit method. Staring with clonazepam 0.5 mg, the pill may be cut in half and dissolved in a small glass of water. The solution may then be rinsed in the mouth for 3 minutes and spit out. This regimen may be repeated three times daily.

Myofascial Pain/Myalgia

Myofascial pain, or myalgia, is a muscular disorder, falling under the umbrella of temoporomandibular joint disorders, and refers to pain caused by muscular trigger points and taut muscle bands. It is characterized by spontaneous dull, aching pain around a particular muscle leading to muscle stiffness and fatigue. Upon palpation, the provider typically palpates a hyperirritable spot within a taut band of muscle that exhibits pain referral when compressed. Patients may also show decreased range of motion and weakness of that muscle. 22 There are multiple treatment modalities for myofascial pain, including topicals such as NSAIDs, anesthetics, and capsaicin cream, as outlined below.

Topical Options for Myofascial Pain

NSAIDS: The NSAID diclofenac inhibits the enzyme cyclooxygenase and ultimately leads to reduced inflammatory mediators (ie, prostaglandins, thromboxanes, and prostacyclins). 23 It is available in several forms, including gels, patches, creams and lotions. 16 A double-blind, placebo-controlled randomized study comparing a diclofenac sodium 60-mg patch and a control menthol patch in patients with cervical myofascial pain showed that patients using the diclofenac sodium patch had a greater reduction in pain scores and better functional outcomes. Adverse effects included skin irritation and erythema, but these were more prevalent in the control group. 23

Diclofenac gel 1% may also be applied externally to the site of pain. Systemic absorption of both the gel and patch forms are significantly lower compared to a single oral 50 mg diclofenac dose. 24 The recommended dose for the diclofenac gel used in the upper extremities (eg, hand, elbow, and wrist) is 2 g per joint application, with a maximum of 8 g per joint per day. Based on the size of the masseter and TMJ region, the recommended dose is 1 g up to 4 times per day. (Note: these dose recommendations are based on anecdotal reports. A patient should not use more than a total of 32 g of gel per day. 24)

Other topical NSAID preparations such as ketoprofen, aspirin, and ibuprofen, may be made by a compounding pharmacy. 2 Evidence is limited in the orofacial pain literature regarding the use of topical NSAIDs for masticatory myofascial pain. However, a recent systematic review found that topical diclofenac, ketoprofen, and piroxicam showed good pain relief for acute musculoskeletal (MSK) pain, such as for sprains or strains. 25 Unfortunately, there is no evidence to date to show that topical NSAIDs are effective in the management of chronic MSK pain. 26 Reported adverse effects with topical NSAIDs were minimal and no greater than those of the topical placebo. 25 Topical NSAIDs may, however, be useful in patients who are susceptible to the gastrointestinal side effects of oral NSAIDs.

Anesthetics: The most widely used topical anesthetic for myofascial pain is the lidocaine patch 5%, which has shown to be effective in decreasing pain and improving quality of life. 27 The lidocaine patch may be applied over 12 hours. The eutectic mixture of local anesthetic (EMLA) cream is a combination of 2.5% lidocaine and 2.5% prilocaine that is also available as a topical analgesic. Its recommended application is four times a day to the affected site. 17 In addition, the 70-mg lidocaine/70-mg tetracaine patch offers another alternative. While the lidocaine 5% patch provides analgesia without anesthesia, the EMLA cream and lidocaine/tetracaine patch result in both analgesia and skin anesthesia. 16

Capsaicin: Capsaicin cream offers another potential alternative for myofascial pain. In patients with soft tissue pain, capsaicin cream 0.05% has showed reduced pain scores compared to placebo. 28 Overall, the capsaicin cream was well tolerated, however, those applying the capsaicin cream experienced more adverse events than those in the placebo group. While evidence for both topical anesthetics and capsaicin for the management of myofascial pain in the orofacial region is limited, studies of other muscle groups have shown benefit.

Temporomandibular Joint Arthralgia

TMJ arthralgia describes pain or tenderness on palpation of the temporomandibular joints. Arthralgia may be associated with disc displacements and osteoarthritis. Patients with disc displacements exhibit symptoms of clicking and locking. Disc displacements may be detected clinically on examination, as well as through imaging (eg, MRI) when needed. Those with osteoarthritis of the TMJs exhibit crepitus on joint function. Degenerative changes to the TMJs may be detected on imaging, such as a cone-beam CT. On examination, the joint noises in both disc displacement and osteoarthritis may be detected through auscultation.

Topical medications used to manage arthralgia include NSAIDs, anesthetics, and capsaicin cream. The class of medications and dosages are the same as those described above for myalgia and myofascial pain. Additional topical options are described below.

Diclofenac gel: Externally applied diclofenac gel 1% is often the first choice among topicals for arthralgia. The recommended dose is 1 g up to 4 times per day applied to the TMJ region, with a maximum dose of 32 g of gel per day. 24 Topically applied diclofenac and oral diclofenac have been found to be equally effective in the treatment of TMJ disorder symptoms, with topically applied diclofenac having the advantage of little to no adverse systemic effects. 29

Compounded NSAIDS: Sufficient, high quality evidence for compounded topical NSAIDs (eg, ketoprofen, aspirin, and ibuprofen) is scarce, however, a semi-recent systematic review evaluating these drugs for the management of pain due to TMJ degenerative joint disease described one double-blind, randomized, placebo-controlled trial that showed benefit. 30 While there were no significant differences in pain relief between the other treatment groups, patients using the topical NSAIDs reported improvement compared to the placebo group.

Corticosteroids: Corticosteroids inhibit phospholipase A2, which prevents the conversion of lips to arachidonic acid, ultimately inhibiting the inflammatory cascade. They have a stronger anti-inflammatory effect than NSAIDs and may be utilized topically using ultrasound (phophoresis) or electrical current (iontophoresis), which drives the corticosteroid into the joint. Reid, et al. compared iontophoresis with dexamethasone in a lidocaine vehicle to placebo in patients with TMJ disorder. Three sessions were completed over 5 days, and patients were followed-up at 7 and 14 days. Compared to placebo, those receiving iontophoresis showed more improvement. 31

Emerging Therapies in Orofacial Pain

Tetrahydrocannabinol and Cannabinol as a Spray

Cannabinoids have been identified as potential adjuvant analgesics and are currently under investigation for a variety of conditions, which may soon include orofacial pain. The natural cannabis plant (Cannabis Sativa L) contains more than 60 cannabinoids, including the potential therapeutic components known as tetrahydrocannabinol (THC) and cannabinol (CBD).

Tetrahydrocannabinol (THC)/Cannabinol(CBD) oromucosal spray is formulated from plant-based extracts prepared from the plant’s genetically distinct chemotypes and contains an approximately 1:1 ratio of THC:CBD, plus smaller amounts of other compounds, including minor cannabinoids and terpenes. 32 THC/CBD spray is licensed in Canada for the treatment of central neuropathic pain in patients with multiple sclerosis (MS), as well as in the European Union, Israel, and New Zealand for relief of spasticity in MS. A 2014 study in Europe concluded that THC/CBD spray showed significant improvement in peripheral neuropathic pain. 33 Another study found that THC/CBD spray was effective for the relief of intractable pain in patients who experienced inadequate analgesia despite chronic opioid treatment. 34,35

Isolated in 1963, CBD lacks psycho-activity, and does not appear to bind to CB1 or CB2 receptors, but rather interacts with a multitude of various ion channels, enzymes, and other receptors that are believed to explain its analgesic, anti-nausea, anti-emetic, anti-epileptic, anti-inflammatory, anxiolytic, anti-ischemic, and anti-psychotic properties. 36-40

With orofacial pain, CBD may be used topically or as an intra-oral spray for neuropathic pain, and/or as an anti-inflammatory agent.

Traumeel as an Integrated Approach

Traumeel is a homeopathic medication produced in oral, topical, and injectable forms. Its mechanism of action is that of an immune system modulator. The activity minimizes the negative effects of inflammation, while allowing aspects of the positive prostaglandin activities to occur. This action is contrary to cortisone, which simply suppresses the immune function. When used topically traumeel is readily absorbed and has been recommended for use with trauma, injuries, physical therapy, and soft tissue and inflammatory joint conditions. 41

A fixed combination of plant and mineral extracts, traumeel may also be used to treat inflammation and pain caused by MSK injuries. 42 Randomized clinical trials have demonstrated reductions in pain and swelling, and improvements in the mobility of joints, such as the ankle and knee. 43-45 Traumeel has further demonstrated efficacy similar to conventional therapies, NSAIDS, and diclofenac. 46-48 Traumeel is well tolerated and presents with very few adverse effects. 49-51 Traumeel use for pain relief may offer an option without the risks of steroids, opioids, or NSAIDS, according to recent multicenter studies. 52,53

While recent research regarding traumeel focused on the knee joint, traumeel ointment has been used for years to treat orofacial pain topically—as an anti-inflammatory agent. Anecdotally, it has been utilized for MSK pain as well as TMJ pain with favorable results.

Conclusion

Common orofacial pain disorders are diverse, including neuropathic pain, myalgia and myofascial pain, and temporomandibular joint arthralgia. While management of these disorders may be varied and often require multidisciplinary approaches, pharmacotherapeutics represent an important treatment option. Topical medications, in particular, may offer several advantages, including: reduced systemic side effects; lessened potential for drug-drug interactions; the ability to provide direct, local analgesia; and improved patient compliance.

Common topical medications used to manage orofacial neuropathic pain include: anesthetics; capsaicin; compounded formulas involving anticonvulsants, tricyclic antidepressants, clonidine, ketamine, and clonazepam. Effective topical agents for myalgia, myofascial pain and TMJ arthralgia include topical NSAIDs, anesthetics, and capsaicin. Topical corticosteroids may be applied for arthralgia as well.

Looking ahead, as research continues, cannibinoids and traumeel may soon offer alternative topical medications for the management of orofacial pain conditions as well.