DEAR DR. ROACH: Two years ago, I was diagnosed with atypical trigeminal neuralgia. This causes me constant and extreme face pain, like a vise-grip on my face. Once an MRI confirmed no brain issues, and after multiple medications including Botox injections, I was put on nortriptyline, which immensely improved the pain. I am 61 years old and currently on 50 mg of nortriptyline, which brought my pain level from a constant 8 to a 2.

After reading your recent column regarding amitriptyline and memory issues, I confirmed that nortriptyline could cause the same issues. I have noticed some minimal memory recall issues after being on this drug for a year. Since no other drug provided any substantial relief (including gabapentin), I believe I will be taking this long-term.

Is there any over-the-counter medicine or any other meds that can counteract the memory side effects of this drug? Also, are you aware of any other successful new treatments for atypical trigeminal neuralgia? I have researched and tried most of the suggested online treatments. — A.M.

ANSWER: Having spoken with many people with trigeminal neuralgia (a facial pain syndrome), I can confirm that the “textbook” case is probably the atypical one. There are many variations of trigeminal neuralgia, and the fact that you had such good relief with nortriptyline is highly suggestive that you do have a nerve-related facial pain syndrome. Although the pain is often intermittent, sometimes the pain can be continuous.

Before making recommendations for changing medications, I want to be sure you understand that you don’t have to change if you don’t want to. Not everybody gets complete relief of pain from an 8 to a 0, and you may decide that it’s worth the memory issues to stay on nortriptyline. It’s unlikely that the memory problems will get worse if they’re really due to nortriptyline.

Since I don’t know which other treatments you’ve had, I’m sorry if I recommend something that hasn’t worked for you. What works really well for one person may not help another. Still, carbamazepine has become the first choice for many experts in the treatment of this painful condition. People with East or South Asian ancestry should consider genetic testing prior to starting this medicine.

Advanced imaging (MRI with MRA, or magnetic resonance angiography) sometimes shows a blood vessel that is compressing the trigeminal nerve. I don’t know if you had the ideal imaging protocol, and a second opinion may be warranted. Consideration of surgery is warranted if this is seen, although this is not a guarantee of success nor that the success will be permanent.

Many of my readers have found benefit from the Facial Pain Association at FacePain.org. They can also help you find experts near you to discuss treatments.

DEAR DR. ROACH: I take Centella asiatica and pycnogenol to help prevent heart disease. Are these effective? — A.N.

ANSWER: Neither Gotu kola (Centella asiatica) nor pycnogenol (maritime pine bark extract) have been proven to reduce the risk of heart disease. Small studies have suggested some benefit in lowering sugar levels, for example, and helping certain eye damage in people with diabetes. But a well-done review didn’t find a benefit in reducing the main drivers of heart disease.

It is possible that these treatments are effective, but there is not strong enough evidence for me to recommend them. You could better spend the money needed for these supplements on a healthy diet.

Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu. (c) 2025 North America Syndicate Inc. All Rights Reserved