Trigeminal Neuralgia
Ronald Brisman, M.D.

Pregnancy Trigeminal Neuralgia

 Female Reproductive Issues and Trigeminal Neuralgia

 Effects of medicines for trigeminal neuralgia are the most important factors affecting female reproductive issues.

There is very little information about trigeminal neuralgia and pregnancy because most people with trigeminal neuralgia are over 50 years old. Occasionally there is a younger female patient with trigeminal neuralgia who is of child-bearing age. Some, but not all of these younger patients, may also have multiple sclerosis. The effects of medications especially antiepileptics (anticonvulsants or anti-seizures) such as carbamazepine (Tegretol), oxcarbazepine (Trileptal), phenytoin (Dilantin), gabapentin (Neurontin), pregabalin (Lyrica), lamotrigine (Lamictal), topiramate (Topamax) or clonazepam (Klonopin) that are often effective in relieving the pain of trigeminal neuralgia are the most important factors in affecting female reproductive issues. Most of the medical information about anti-seizure medicines and the fetus or lactation comes from experience with epilepsy patients where there may be more damage to the fetus and mother from uncontrolled seizures. We can use some of this information to inform patients with trigeminal neuralgia who are of child-bearing age.

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 Contraception and trigeminal neuralgia

Before a woman of child-bearing age gets pregnant, there are often concerns about contraception. Antiepileptic medicines, especially carbamazepine and oxcarbazepine may interfere with contraceptive pills and may make such pills less effective. Patients with trigeminal neuralgia who require anti-seizure medicines to control their face pain may want to consider alternative forms of contraception.

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 The best time to do a neurosurgical procedure for trigeminal neuralgia is before or after a pregnancy.

Patients who are anticipating a pregnancy and are having trigeminal neuralgia pain that requires anti-seizure medicine may want to consider a neurosurgical procedure to relieve their pain before they get pregnant.

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 The greatest risk to the fetus is during the first trimester of pregnancy.

Although there is a risk to the fetus throughout a pregnancy, the greatest risk is during the first trimester. Special effort should be made to avoid anti-seizure medicines or neurosurgical intervention during this time. However, I have been reluctant to do a neurosurgical procedure at any time during a pregnancy.

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 It is better (for the fetus) that the mother take no medicines or only one at the lowest dose.

Taking more than one anti-seizure medicine at a time is probably more harmful to a fetus than taking only one. Even though anti-seizure medicines may adversely affect a fetus, the chance of this happening is small and perhaps 4 percent for carbamazepine. It might be lower for lamotrigine (Lamictal). Regular pain relievers (analgesics), such as acetaminophen or oxycodone probably have a smaller chance of adversely affecting a fetus, but they are also less effective in relieving trigeminal neuralgia.

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 Anti-convulsant medicines that cross the placenta

Phenytoin, carbamazepine, levetiracetam (Keppra) and valproate (Depakote) probably cross the placenta in potentially clinically important amounts (one Class I and supporting Class II studies or two or more Class II studies; both Class I and II are controlled clinical trials and represent the best kind of clinical study; Class I is the most rigorous of the four classes). Gabapentin, lamotrigine, oxcarbazepine and topiramate possibly cross the placenta in potentially clinically important amounts (at least one Class II Study for each) http://www.neurology.org/content/73/2/142.full.

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 The safest way to manage trigeminal neuralgia during a pregnancy

One option that is always available for a patient with trigeminal neuralgia, and especially for those who are pregnant, is to wait and do nothing except perhaps take a mild analgesic (acetaminophen) since trigeminal neuralgia often subsides spontaneously without any known reason or intervention. Other pharmaceutical options include the intraoral application of a local anesthetic such as benzocaine (Orajel or Anbesol), the application of a lidocaine patch on the face or capsaicin cream. Unfortunately, these are usually not very effective. Patients who have trigeminal neuralgia and are considering pregnancy and/or breast-feeding should discuss the pros and cons of medicines or other treatments with their doctors. It is best to take no medicines or, if absolutely necessary, to take fewer medicines at lower doses.

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 Lactation and medicines to treat trigeminal neuralgia

Some anti-seizure medicines get into the mother’s milk. Levetiracetam probably penetrates into breast milk in potentially clinically important amounts. Gabapentin, lamotrigine and topiramate possibly penetrate into breast milk in potentially clinically important amounts. Valproate, phenytoin and carbamazepine probably do not penetrate into breast milk in potentially clinically important amounts or at least to a lesser degree than the other anti-seizure medicines http://www.neurology.org/content/73/2/142.full.

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 Recent FDA recommendations

Recently (December 2014) the FDA (Food and Drug Administration) indicated that it is no longer recommending the use of risk categories for pregnancy (A,B,C,D,X) because they can be misleading. Instead, the final rule requires that that labeling include a summary of the risks of using a drug during pregnancy and lactation, a discussion of the data supporting that summary and relevant information to help health care providers make prescribing decisions and counsel women about the use of drugs during pregnancy and lactation http://federalregister.gov/a/2014-28241.

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 Table of medicines for trigeminal neuralgia and their risks to a fetus or baby (from lactation)

TABLE 1: MEDICINES USED FOR TRIGEMINAL NEURALGIA AND THEIR SAFETY/RISK TO FETUS OR BABY (FROM LACTATION)

Generic Name Trade Name Type Pregnancy Risk* Lactation Risk**
carbamazepine Tegretol Anticonvulsant D Probably Safe
oxcarbazepine Trileptal Anticonvulsant C Safety unknown
gabapentin Neurontin Anticonvulsant C Probably Safe
pregabalin Lyrica Anticonvulsant C Safety unknown
levetiracetam Keppra Anticonvulsant C Probably Safe
lamotrigine Lamictal Anticonvulsant C Unsafe
phenytoin Dilantin Anticonvulsant D Probably Safe
topiramate Topamax Anticonvulsant D Safety unknown
clonazepam Klonopin Anticonvulsant D Safety unknown
divalproex sodium Depakote Anticonvulsant D Probably Safe
baclofen Lioresal Muscle relaxer C Possibly Unsafe
codeine sulfate   Pain reliever, narcotic C Possibly Unsafe
oxycodone OxyContin Pain reliever, narcotic B Probably Safe
acetaminophen Tylenol Pain reliever B Safe
benzocaine Anbesol, Orajel Pain reliever C Probably Safe

*Risk Categories (FDA): http://chemm.nlm.nih.gov/pregnancycategories.htm : B. Animal reproduction studies have failed to demonstrate a risk to the fetus and there are no adequate and well-controlled studies in pregnant women.
C: Animal reproduction studies have shown an adverse effect on the fetus and there are no adequate and well-controlled studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks.
D: There is positive evidence of human fetal risk based on adverse reaction data from investigational or marketing experience or studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks.

**Lactation Risk:
Possibly Unsafe: Available animal and/or human data demonstrates potential or actual adverse effects to infant/breast milk production; consider alternatives or weigh risk/benefit.
Probably safe: Limited information in animals and/or human demonstrates no risk/minimal risk of adverse effect to infant/breast milk production. Caution advised.

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