Trigeminal Neuralgia

1. This type of pain is of too short duration to catch it with an abortive, or “as-needed” treatment. Therefore, the goal of treatment is focused on preventive therapy: What to take on a daily basis to try to lessen the frequency and/or severity of the pain. Preventive medicines can take several weeks to start working, assuming the correct dose of the medication is reached. These are the medications used most commonly, although this is not an all-inclusive list.
   1. Anti-convulsant (Anti-seizure) medications:
      ---Carbamazepine (Tegretol) (considered a 1st line option)
      ---Oxcarbazepine (Trileptal) (considered a 1st line option)
      ---Gabapentin (Neurontin)
      ---Pregabalin (Lyrica)
      ---Topiramate (Topamax)
      ---Lamotrigine (Lamictal)
      ---Divalproex sodium (Depakote)
      ---Lacosamide (Vimpat)
      ---Zonisamide (Zonegran)
   2. Anti-depressant/Anti-anxiety medications:
      ---Amitriptyline (Elavil)
      ---Nortriptyline (Pamelor)
      ---Venlafaxine XR (Effexor XR)
      ---Desvenlafaxine (Pristiq)
      ---Duloxetine (Cymbalta)
   3. Muscle relaxants:
      ---Baclofen (Lioresal)
   4. Biologics:
      ---Botox
   5. Ablative/Surgery:
      ---SPG (sphenopalatine ganglion) blocks or SPG neurostimulation
      ---Microvascular decompression (MVD) (considered 1st line treatment in classical trigeminal neuralgia with neurovascular compression after failing medications)
      ---Gamma knife radiosurgery
      --- Glycerol injection
      ---Balloon compression
      ---Radiofrequency thermal lesioning

If patients fail conservative medication trials (or can not tolerate them), and if there is neurovascular compression of the trigeminal nerve on MRI, then microvascular decompression (MVD) is considered treatment of choice. Studies have shown that 62-89% of patients continue to be pain free in follow up after 3-11 years. Severe rare complications can include edema, bleeding, or stroke (0.6%), anaesthesia dolorosa (0.02%), meningitis (0.4%), or death (0.3%). Less severe complications can include hearing loss (1.8%), facial numbness (3%), and cranial nerve palsy (4%).

If patients fail conservative medication trials (or can not tolerate them), and if there is no neurovascular contact of the trigeminal nerve on MRI, then ablative treatments are the preferred treatments. Studies show that during a follow up of 4-11 years, 30-66% were pain free with gamma knife, 55-80% were pain free after balloon compression, 26-82% were pain free after radio frequency thermocoagulation, and 19-58% were pain free after glycerol injection. Potential complications after these procedures as a whole are facial numbness (19%), corneal numbness (5%), trigeminal motor weakness (5%), anaesthesia dolorosa (0.5%), and meningitis (0.7%).

If patients fail conservative medication trials (or can not tolerate them), and if there is neurovascular contact but not compression of the trigeminal nerve on MRI, then microvascular decompression (MVD) and ablative procedures are equal first line treatment choices.