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Received: 16 May 2019    Revised: 4 July 2019    Accepted: 22 July 2019

DOI: 10.1111/jicd.12448

REVIEW ARTICLE

Efficacy of gabapentin in the treatment of trigeminal neuralgia:

A systematic review of randomized controlled trials

Patrick Chieu Poa Ta1 | Hue Quyen Dinh1 | Kim Nguyen1 | Samuel Lin1 | Yong Li Ong1 |

Anura Ariyawardana1,2

1
College of Medicine and Dentistry, James
Cook University, Cairns, QLD, Australia
2
Metro South Oral Health, Queensland
Health, Brisbane, QLD, Australia
Correspondence
Anura Ariyawardana, College of Medicine
and Dentistry, James Cook University,
Cairns, Australia.
Email: anura.ariyawardana@jcu.edu.au
Abstract
The aim of this systematic review was to determine the efficacy of gabapentin
(GBP) in the treatment of pain of  idiopathic trigeminal neuralgia (TN). A compre‐
hensive literature search was conducted using the Cumulative Index of Nursing and
Allied Health Literature (EBSCO Industries), Emcare (Ovid), Medline (Ovid), Medline
(PubMed), Scopus (Elsevier) and Web of Science (Clarivate Analytics). The inclusion
criteria comprised randomized controlled trials of GBP as a monotherapy in the treat‐
ment of idiopathic TN in adult participants and publications in English. All other study
methodologies were excluded. The search yielded 1472 articles, and after exclusion,
11 full‐text articles were eligible for full‐text analysis. Only two studies met the inclu‐
sion criteria. There is insufficient evidence either to support or refute the efficacy of
GBP in the management of idiopathic TN. Therefore, further well‐designed placebo‐
controlled trials are required to confirm the efficacy of GBP in managing TN pain as
a single therapy.

KEYWORDS
gabapentin, neuropathic, pain, systematic review, trigeminal neuralgia

1 |  I NTRO D U C TI O N describe a history of sudden shooting or stabbing pain, separated

Trigeminal neuralgia (TN), or tic douloureux, is a clinical syndrome
characterized by brief, electric shock‐like pain of abrupt onset and
termination that is limited to the distribution of one or more divi‐
1
sions of the trigeminal nerve. Pain is typically evoked by non‐nox‐
ious sensory stimuli including washing the face, talking, shaving and
the force of wind, but is also known to occur spontaneously in any
2
area innervated by the trigeminal nerve. The pain is often abrupt
in onset and termination, and may relapse with pain‐free intervals
varying from a few days to several years. 2,3
The incidence of TN is roughly 4.3/100 000 persons per year,
being slightly more prevalent in women (5.9/100 000) than men
(3.4/100 000).4 The treatment is challenging due to ambiguity sur‐
rounding the precise etiology and pathophysiology of TN. This is
because diagnosis of TN remains clinical and relies heavily upon the
subjective experience of the patient. Ideally, the patient is able to
by pain‐free intervals. High‐resolution magnetic resonance imaging
can also be used but as an adjunct as opposed to being a defini‐
tive diagnostic tool.5 Obermann provides a comprehensive outline
of the treatment options available.4 Not all of them are universally
effective or tolerable to patients and therefore pharmacotherapy
is considered the first‐line management for TN as a minimally inva‐
sive approach.4 Surgical procedures are only recommended among
patients who are refractory to conservative approaches.4,5
Current evidence‐based treatment guidelines recommend car‐
bamazepine (CBZ; 200‐1200 mg/day) and oxcarbazepine (OXC;
600‐1800 mg/day) as first‐line therapy.6,7 Second‐line treatment
is based on minimal evidence and involves add‐on therapy with la‐
motrigine (400 mg/day).8 However there is interest in alternative
therapies as a small percentage (6%‐10%) of patients are intolerant
to CBZ.9 Alternative treatment options involve other antiepileptic
drugs such as lamotrigine, gabapentin (GBP), OXC, baclofen and

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https://doi.org/10.1111/jicd.12448
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2 of 6       TA et al

pregabalin.10 Of these newer drugs, GBP is of particular interest due 2 | M ATE R I A L S A N D M E TH O DS
to its minimal interaction with other medications and fewer side‐ef‐
fects. GBP has shown efficacy alone and in combination with local 2.1 | Information sources and search strategy
injections of ropivicaine.4,11 The chemical formula for GBP is 1‐(ami‐
This systematic review was registered with the International
nomethyl) cyclohexaneacetic acid and was approved for the control
Prospective Register of Systematic Reviews (PROSPERO) (registra‐
of partial seizures in 1994 by the US Food and Drug Administration,
tion no. PROSPERO 2018, CRD42018087368).
under the brand name Neurontin®.12 The gabapentinoid is an oral
A comprehensive literature search was performed using the fol‐
medication in the form of a tablet or capsule. It is absorbed in the
lowing electronic databases: Cumulative Index of Nursing and Allied
small intestines, not metabolized by the body and excreted in the
Health Literature (EBSCO Industries), Emcare (Ovid), Medline (Ovid),
urine unchanged.13 GBP is part of a new generation of antiepilep‐
Medline (PubMed), Scopus (Elsevier) and Web of Science (Clarivate
tic medications which have many therapeutic applications, and are
Analytics). The search was finalized on 22 July 2018. No other search
notably effective for treatment of epilepsy, postherpetic neuralgia14
modalities were used to retrieve additional literature. The search
and diabetic peripheral neuropathy.15 Other uses that have weaker
was restricted to literature written in English. No restrictions were
evidence include alcohol cessation,16 treatment of anxiety in breast
placed on the year or location of publication. The search strategies
cancer survivors17 and delay of the natural progression of amyo‐
used to obtain the articles are outlined in Table 1.
trophic lateral sclerosis.18
There are no systematic reviews on the efficacy of GBP for pain
2.2 | Eligibility criteria
management in TN patients to date. A Cochrane Review in 2007 by
Wiffen et al analyzed GBP’s use in different neuropathic pains but Randomized controlled trials (RCT) of GBP in the treatment of idi‐
they did not identify any studies on TN. 20 However, one large‐scale opathic TN in adult participants were included. This review included
retrospective study on 92 cases reported that GBP should be con‐ interventions which used GBP systemically as a monotherapy and
sidered as an alternative treatment option and highlighted its supe‐ comparator studies to control pain associated with TN. Studies
rior safety profile.19 Eisenberg et al conducted another systematic which were non‐RCT, case reports, case series analysis and papers
review on the use of different antiepileptic agents for neuropathic published in non‐English languages were excluded.
pain; again, the use of GBP for TN was not investigated. 21 Thus,
there is a need for a detailed investigation of current evidence re‐
2.3 | Outcome measures
garding the efficacy of GBP in the control of pain associated with
TN. Therefore, the main objective of this systematic review was to The primary outcome was the relief of pain associated with idi‐
ascertain the effectiveness of GBP in the control of pain associated opathic TN. Secondary outcomes were level of pain relief, longevity
with TN. of pain relief and quality of life.

TA B L E 1   Databases accessed with

Keywords (MeSH) term and text word
corresponding search strategies
  Database (company) search

1 CINAHL (EBSCO Industries) (gabapentin OR gabapentin encarbil OR

2 Emcare (Ovid)
3 Medline (Ovid)
4 Medline (PubMed)
5 Scopus (Elsevier)
6 Web of Science (Clarivate
Analytics)
neurontin OR horizant OR regnite) AND
(trigeminal neuralgia OR TN OR TGN
(gabapentin OR gabapentin encarbil)
AND (trigeminal neuralgia OR trigemi‐
nus neuralgia)
(gabapentin OR gabapentin encarbil OR
neurontin OR horizant OR regnite) AND
(trigeminal neuralgia OR TN OR TGN
(gabapentin OR gabapentin encarbil OR
neurontin OR horizant OR regnite) AND
(trigeminal neuralgia OR TN OR TGN)
(gabapentin OR encarbil OR neurontin
OR horizant OR regnite) AND (trigemi‐
nal neuralgia OR TN OR TGN)
(gabapentin OR gabapentin encarbil OR
neurontin OR horizant OR regnite) AND
(trigeminal neuralgia OR TN OR TGN)

Abbreviation: MeSH, Medical Subject Headings.

TA et al
2.4 | Quality of evidence
The quality of evidence from included RCT were graded as high,
moderate, low or very low based on the GRADE criteria. Reasons
for downgrading included risk of bias, inconsistency, indirectness,
imprecision and publication bias. Reasons for upgrading included
large effect size, when all plausible residual confounders would tend
to underestimate the size of the effect or the presence of a dose‐re‐
sponse gradient. 22
2.5 | Selection of studies
After the removal of duplicates, five review authors (PCPT, HQD,
KN, SL and YLO) selected articles through the evaluation of titles
and abstracts as per the PRISMA guidelines (Figure 1). Studies of po‐
tential relevance were obtained in full for independent assessment.
The reviewers decided which articles satisfied the inclusion criteria.
Disagreements throughout the process were settled by consensus.
2.6 | Data extraction and management
Information collected from each eligible study included sample size,
comparability of groups at baseline, GBP dose, type of active control
intervention and dose, study design, study duration and follow up,
analgesic outcome measures and results, withdrawals and adverse
effects. five review authors (PCPT, QD, KN, SL and YLO) indepen‐
dently extracted and checked data on participants, methods, inter‐
ventions, outcomes and results using an electronic Microsoft Excel
spreadsheet (Microsoft).
2.7 | Assessment of risk of bias in included studies
5 review authors (PCPT, HQD, KN, SL and YLO) worked indepen‐
dently using the Cochrane risk‐of‐bias tool to ascertain the valid‐
ity of eligible randomized trials. The assessment considered the
sequence generation, allocation concealment, blinding, incomplete
outcome data, selective outcome reporting and any other potential
F I G U R E 1   PRISMA flowchart of
screening of studies. RCT, randomized
controlled trial; TN, trigeminal neuralgia
|
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bias, as described in the Cochrane Handbook for Systematic Reviews
of Intervention. 23 A calibration exercise among the review team
members was performed to ensure adequate reliability.
3 | R E S U LT S
The electronic database search yielded 1472 studies and after the
removal of duplicates, 929 remained. Based on the titles and ab‐
stracts, 918 studies were excluded yielding 11 for full‐text review.
Based on the inclusion criteria, five review authors (PCPT, KHQD,
KN, SL and YLO) independently evaluated the 11 articles in full. Of
the 11 articles, two articles were included for full review and nine
articles were excluded (three articles excluded due to no randomiza‐
tion, four articles due to the use of GBP in combination therapy and
two due to no TN as specific treatment) (Figure 1). Details of the
excluded studies are given in Table 2. The risk of bias assessment is
depicted in Figure 2.
Debta et al conducted a study in Ahmedabad, India, among 53
patients with TN. 24 This study included both newly diagnosed and
refractory patients. Seventeen out of 53 were treated with GBP
and 35 with OXC therapy for 6 months. One participant was lost
to follow up. In newly diagnosed TN patients, GBP’s therapeutic ef‐
fectiveness was determined to be 60%‐80% whilst it was 50%‐60%
in refractive patients. Despite these values, GBP was found to be
inferior to OXC. 24
Lemos et al conducted a study in Alto Ave, Portugal, with 42
TN partients.11 Of these, 36 met the criteria for the diagnosis of id‐
iopathic TN and experienced pain equal or greater than six on the
visual analog scale. Six participants were excluded based on the
exclusion criteria. Participants were randomly allocated into three
groups: protocol I, treated with GBP only; protocol II, with ropiva‐
caine (ROP) block only; and protocol III, a combination of ROP and
GBP (ROP + GBP).
At the end of the experimental period, both protocol I and pro‐
tocol III showed effectiveness in controlling pain in all 12 patients;
however, there was a significant reduction in pain following the
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TA B L E 2   Summary of papers excluded after reading the full paper

Reason for
  Author, country Objectives of the study exclusion

1 Cheshire, 2002,
USA19
2 Di Stani et al, 2015,
Italy27
3 Hall et al, 2008,
UK 28
4 Jenson et al, 2001,
USA 29
5 Lemos et al, 2011,
Portugal30
6 Pizza et al, 1997,
Italy31
7 Serpell, 2002, UK32
8 Silver et al, 2007,
USA33
9 Yadav et al, 2015,
India34
To survey the cumulative experience with gabapentin for patients with trigeminal Not an RCT
neuralgia seen at the Mayo Clinic in Jackonsville, FL, USA.
To generate hypotheses for future randomized controlled study to evaluate the ef‐ Combination
ficiency of combination therapeutic approach in CTN pain management. therapy
To investigate current prescribing patterns and to update the incidence estimates for Not an RCT
neuropathic pain syndromes.
To explore the possible use of gabapentin (Neuontin®) and levetiracetam (Keppra®) in No TN‐specific
combination for neuropathic pain utilizing a prospective open‐label trial. treatment
To compare the clinical outcome and direct costs of: (a) a first‐line pharmacological Combination
treatment (CBZ); (b) the therapeutic association of GBP and the peripheral analgesic therapy
block of TN trigger‐points with ROP (GBP + ROP); and (c) a common TN surgery
(MDV) in patients recruited from the same country region.
To verify the efficacy of treatment with gabapentin to trigeminal neuralgia. Not an RCT
To examine the safety and efficacy of gabapentin at doses of up to 2400 mg/day in a No TN‐specific
wide range of neuropathic pain syndromes. treatment
To evaluate the efficacy and tolerability of lamotrigine added to gabapentin, a tricyclic Combination
antidepressant, or a non‐opioid analgesic in patients whose neuropathic pain was therapy
inadequately controlled with these medications.
To evaluate the retrospective data of the patients diagnosed with idiopathic trigeminal Combination
neuralgia and to understand the disorder in the Indian populace. therapy

Abbreviations: CBZ, carbamazepine; CTN, classic trigeminal neuralgia; GBP, gabapentin; MDV, microvascular decompression; RCT, randomized con‐
trolled trial; ROP, ropivacaine; TN, trigeminal neuralgia.

F I G U R E 2   Risk of bias summary: review authors’ judgements about each methodological quality item for each included study. Red = high
risk of bias; yellow = unclear risk of bias; green = low risk of bias

ROP + GBP treatment compared with the GBP‐only treatment. 4 | D I S CU S S I O N

Although protocol II showed reduction in pain, seven participants
had to drop out before the 1st weekly follow up due to incomplete
pain control and had to be moved to either CBZ or GBP therapy.
Five months after the 28‐day research, participants who had under‐
gone ROP + GBP treatment showed the least number of daily pain
episodes while the GBP‐treated group showed an increased number.
11 months post‐research, the ROP + GBP‐treated group showed a
significantly lower number of daily pain episodes compared with
both GBP‐treated and ROP‐treated groups. The ROP + GBP‐treated
group also showed an increased value of quality of life compared
with the group treated with GBP only.11
Only in the study conducted by Lemos et al was the statistical
analysis performed and therefore it was not possible to compare the
heterogeneity between the trials through meta‐analysis.11 Instead, a
qualitative analysis of both studies was carried out.
The gabapentinoid is a synthetic analog for γ‐aminobutyric acid
(GABA) that is found naturally in the body as a neurotransmitter.
GABA in the central nervous system provides inhibitory activity
for neuronal excitability. 25 Rogawski and Taylor identified a calcium
channel blocker α2‐δ with 2 subunits α2‐δ‐1 and α2‐δ‐2 that they
hypothesized was responsible for the action of GBP. 26 When GBP
and the receptor bind, there is a reduction in calcium ion influx to pr‐
esynaptic terminals. However, the article concludes that they could
not definitively describe how binding of GBP to this receptor caused
the therapeutic qualities of the antiepileptic drug. 26 Therefore, the
pharmacodynamics of GBP are still yet to be confirmed. Based on
the guidelines outlined by Ryan and Hill, both articles were re‐evalu‐
ated in line with their recommendations. 22
TA et al
Selection of participants in Debta et al’s study was found to be
24
somewhat flawed. The patients were randomly recruited from the
hospital; however, the small sample size and unidentifiable demo‐
graphic aspects (age, sex, division of nerve involved or side of face
affected) were not representative of the population under investi‐
gation. Therefore, the study results cannot be extrapolated to the
wider population. Furthermore, the lack of allocation concealment
and blinding of either participants and/or researchers in the study
was a noticeable flaw.
There was a consistent use of outcome measures as baseline and
follow up; however, the methodology of the research was incon‐
sistent: there was an unequal distribution of the participants in the
intervention (N = 35) and control groups (N = 17). This leads to base‐
line imbalance. The clinical heterogeneity could have arisen from the
lack of information available regarding the participants’ backgrounds
in terms of sex, age and race. Overall, in line with GRADE Guidelines,
the study received a “low” level of evidence. 22
On the other hand, the selection of patients in the study per‐
formed by Lemos et al showed greater randomization.11 The se‐
quence was generated whereby the first participant was asked to
choose an envelope from 36 identical‐looking ones, which con‐
tained the allocation of the treatment protocols, and the next par‐
ticipant was to follow the same steps with the remaining envelopes
mixed before they took the envelope. Allocation concealment was
achieved by allowing the participant to take the envelope without
looking inside, therefore not knowing which treatment they had
been allocated to. Should there have been an improvement in the
outcome, it would be less subjective. However, it was not possible to
blind the patient to the treatment itself due to the non‐homogenous
nature of the treatment offered for different groups, namely injec‐
tion and non‐injection. Hence, only the researchers were blinded to
the therapeutic groups and the outcome assessment. Besides the
attrition, which amounted to 20% due to the loss of seven of the
36 participants and therefore introduced bias to the research, there
were no other identifiable risks of bias in this study.
The statistical analysis showed that there was no significant dif‐
ference between participants undergoing different protocols, and
this homogeneity of the sample allowed for standardization of the
results. The mean age of participants across the groups was in the
60s, which makes the sample homogenous; however, that means the
results cannot be extrapolated to the wider population. No other
significant clinical or methodological heterogeneity was identified;
however, there were variances in the TN trigger points and that may
possibly change the response to the treatment. The reported confi‐
dence interval was set at 95%. Overall, the study received a “high”
GRADE level of evidence. 22
Neither study had a large effect on the population due to their
similar limitations: small sample size, issues of blinding and lack of
the long‐term follow up. The general consensus of both studies was
that GBP therapy is an effective treatment for patients with TN;
however, it should still be considered as an alternative to CBZ due
to the latter's significant effect (these results were derived from
large‐scale control studies) or other anticonvulsants such as OXC.
|
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Therefore, GBP should only be prescribed when the patient cannot
tolerate first‐line medication.
Limitations to this systematic review include the use of only
English‐language literature. This might have excluded important
studies reported in different languages. Our literature search also
found numerous case reports and case series showing positive treat‐
ments of TN with GBP. However, they provide low level of scientific
evidence.19,35-41 Although we identified a study that illustrated the
efficacy of GBP, this was not specific to idiopathic TN but focused
on other neuropathic pains such as allodynia, burning pain, shooting
pain and hyperalgesia.32
4.1 | Conclusions
This study identified only 2 RCT studying the efficacy of GBP in the
management of idiopathic TN. There is insufficient evidence either
to support or refute the efficacy of GBP in the management of idi‐
opathic TN. Therefore, further well‐designed placebo‐controlled tri‐
als are required to confirm the efficacy of GBP in managing TN pain
as a single therapy.
ORCID
Anura Ariyawardana  https://orcid.org/0000-0002-4671-7045
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How to cite this article: Ta PCP, Dinh HQ, Nguyen K, Lin S,
Ong YL, Ariyawardana A. Efficacy of gabapentin in the
treatment of trigeminal neuralgia: A systematic review of
randomized controlled trials. J Invest Clin Dent. 2019;e12448.
https​://doi.org/10.1111/jicd.12448​