Figure 4: Stepwise Guidelines for Neuropathic Orofacial Pain
Antidepressants and anticonvulsant medications are the mainstay of pharmacologic treatment for a variety of neuropathic pain syndromes, including postherpetic neuralgia, diabetic neuropathy, fibromyalgia, complex regional pain syndrome, and phantom limb pain, even though most of them are not approved by the FDA for these indications (Table 4). Combining an antidepressant and an anticonvulsant may produce a synergistic analgesic effect in neuropathic pain
syndromes. It is interesting to note that, although many medications used for nociceptive pain may be effective to a certain degree for neuropathic pain, the reverse is not true. In fact, three recent reviews concluded that there is limited to moderate evidence for the efficacy of anticonvulsants in orofacial pain disorders (Martin & Forouzanfar, 2011; Halpern & Willis, 2016; Reyad, Mishriky, & Girgis, 2020).
Table 4: Antidepressants and Anticonvulsant Medications for the Treatment of Neuropathic Pain Syndromes Antidepressant Medications Formulations Usual Daily Dosage for Neuropathic Pain
FDA-Approved Indications
Amitriptyline (Elavil, generics)
10, 25, 50, 75, 100, 150 mg tablets 75, 100 mg tablets 100, 150, 200, 300, 450 mg ER tablets 10, 25, 50, 75, 100, 150 mg tablets
25-100 mg once (usually at bedtime) 100-150 mg qd-bid ER: 100-450 mg once
Depression
Bupropion (Wellbutrin, generics)
Depression Seasonal affective disorder Smoking cessation
Desipramine (Norpramin, generics)
10-25 mg/day; usual effective dose: 50-150 mg/day
Depression
Desvenlafaxine (Pristiq, generics)
50, 100 mg tablets 50, 100 mg ER tablets
50 mg once
Depression
Duloxetine (Cymbalta)
20, 30, 60 mg capsules
60 mg once
Chronic musculoskeletal pain Diabetic neuropathy Fibromyalgia Generalized anxiety disorder Major depressive disorder
Imipramine (Tofranil, generics)
10, 25, 50 mg tablets 75, 100, 125, 150 mg capsules
50-100 mg once or in divided doses
Depression
Milnacipran (Savella)
12.5, 25, 50, 100 mg tablets
50 mg bid
Fibromyalgia
Nortriptyline (Pamelor, generics)
10, 25, 50, 75 mg capsules 2 mg/mL oral solution
75 mg once or in divided doses Depression
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