BNF for Children 2011-2012

212 4.7.3 Neuropathic pain BNFC 2011–20124 Central nervous systempack = £18.26; 150 mg (beige), 60-tab pack = £27.39;200 mg (orange), 60-tab pack = £36.52. Label: 2, 25DoseModerate to severe pain. By mouthChild 12–18 years 50–100 mg twice daily increased ifnecessary to 150–200 mg twice daily; total of more than400 mg daily not usually requiredModified-release 24-hourly preparationsTradorec XL c (MSD) ATablets, m/r, tramadol hydrochloride 100 mg, netprice 30-tab pack = £14.10; 200 mg, 30-tab pack =£14.98; 300 mg, 30-tab pack = £22.47. Label: 2, 25DoseModerate to severe pain. By mouthChild 12–18 years initially 100 mg once daily, increasedif necessary to max. 400 mg once dailyZamadol c 24hr (Meda) ATablets, f/c, m/r, tramadol hydrochloride 150 mg, netprice 28-tab pack = £10.70; 200 mg, 28-tab pack =£14.26; 300 mg, 28-tab pack = £21.39; 400 mg, 28-tabpack = £28.51. Label: 2, 25DoseModerate to severe pain. By mouthChild 12–18 years initially 150 mg once daily increasedif necessary; max. 400 mg once dailyZydol XL c (Grünenthal) ATablets, m/r, f/c, tramadol hydrochloride 150 mg, netprice 30-tab pack = £12.18; 200 mg, 30-tab pack =£17.98; 300 mg, 30-tab pack = £24.94; 400 mg, 30-tabpack = £32.47. Label: 2, 25DoseModerate to severe pain. By mouthChild 12–18 years 150 mg once daily increased ifnecessary; more than 400 mg once daily not usuallyrequiredWith paracetamolsection 4.7.14.7.3 Neuropathic painNeuropathic pain, which occurs as a result of damage toneural tissue, includes compression neuropathies, peripheralneuropathies (e.g. due to diabetes, HIV infection,chemotherapy), trauma, idiopathic neuropathy,central pain (e.g. pain following spinal cord injury andsyringomyelia), postherpetic neuralgia, and phantomlimb pain. The pain may occur in an area of sensorydeficit and may be described as burning, shooting orscalding; it may be accompanied by pain that is evokedby a non-noxious stimulus (allodynia).Children with chronic neuropathic pain require multidisciplinarymanagement, which may include physiotherapyand psychological support. Neuropathicpain is generally managed with a tricyclic antidepressantsuch as amitriptyline (p. 185) or antiepilepticdrugs such as carbamazepine (p. 218). Children withlocalised pain may benefit from topical local anaestheticpreparations section 15.2, particularly whileawaiting specialist review. Neuropathic pain mayrespond only partially to opioid analgesics. A corticosteroidmay help to relieve pressure in compressionneuropathy and thereby reduce pain.For the management of neuropathic pain in palliativecare, see p. 18.Chronic facial pain Chronic oral and facial painincluding persistent idiopathic facial pain (also termed‘atypical facial pain’) and temporomandibular dysfunction(previously termed temporomandibular joint paindysfunction syndrome) may call for prolonged use ofanalgesics or for other drugs. Tricyclic antidepressants(section 4.3.1) may be useful for facial pain [unlicensedindication], but are not on the Dental Practitioners’ List.Disorders of this type require specialist referral andpsychological support to accompany drug treatment.Children on long-term therapy need to be monitoredboth for progress and for side-effects.4.7.4 Antimigraine drugs4.7.4.1 Treatment of acute migraine4.7.4.2 Prophylaxis of migraine4.7.4.3 Cluster headache and the trigeminalautonomic cephalalgias4.7.4.1 Treatment of acute migraineTreatment of a migraine attack should be guided byresponse to previous treatment and the severity of theattacks. A simple analgesic such as paracetamol (preferablyin a soluble or dispersible form) or an NSAID,usually ibuprofen, is often effective; concomitant antiemetictreatment may be required. If treatment with ananalgesic is inadequate, an attack may be treated with aspecific antimigraine compound such as the 5HT 1 -receptor agonist sumatriptan. Ergot alkaloids areassociated with many side-effects and should beavoided.Excessive use of acute treatments for migraine (opioidand non-opioid analgesics, 5HT 1 -receptor agonists, andergotamine) is associated with medication-overuseheadache (analgesic-induced headache); therefore,increasing consumption of these medicines needs carefulmanagement.5HT 1 -receptor agonists5HT 1 -receptor agonists are used in the treatment ofacute migraine attacks; treatment of children shouldbe initiated by a specialist. The 5HT 1 -receptor agonists(‘triptans’) act on the 5HT (serotonin) 1B/1D receptorsand they are therefore sometimes referred to as5HT 1B=1D -receptor agonists. A 5HT 1 -receptor agonistmay be used during the established headache phase ofan attack and is the preferred treatment in those who failto respond to conventional analgesics. 5HT 1 -receptoragonists are not indicated for the treatment of hemiplegic,basilar, or opthalmoplegic migraine.If a child does not respond to one 5HT 1 -receptor agonist,an alternative 5HT 1 -receptor agonist should betried. For children who have prolonged attacks thatfrequently recur despite treatment with a 5HT 1 -receptoragonist, combination therapy with an NSAID such as