How is trigeminal neuralgia (TN) treated?

Updated: Jul 11, 2019
  • Author: Manish K Singh, MD; Chief Editor: Robert A Egan, MD  more...
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Answer

Treatment of TN comprises the following:

  • Pharmacologic therapy

  • Percutaneous procedures (eg, percutaneous retrogasserian glycerol rhizotomy)

  • Surgery (eg, microvascular decompression)

  • Radiation therapy (ie, gamma knife surgery)

Features of pharmacologic therapy are as follows:

  • Pharmacologic trials should always precede the contemplation of a more invasive approach, as medical therapy alone is adequate treatment for 75% of patients

  • Single-drug therapy may provide immediate and satisfying relief

  • Carbamazepine is the best studied drug for TN and the only one with US Food and Drug Administration (FDA) approval for this indication

  • Because TN may remit spontaneously after 6-12 months, patients may elect to discontinue their medication in the first year following the diagnosis; most must restart medication in the future

  • Over the years, patients may require a second or third drug to control breakthrough episodes and finally may need surgical intervention

  • Lamotrigine and baclofen are second-line therapies

  • Controlled data for adding a second drug when the first fails exist only for the addition of lamotrigine to carbamazepine

  • Gabapentin has demonstrated effectiveness in TN, especially in patients with multiple sclerosis

Features of surgical treatment include the following:

  • Three operative strategies now prevail: percutaneous procedures, gamma knife surgery (GSK), and microvascular decompression (MVD)

  • Ninety percent of patients are pain-free immediately or soon after any of the operations, [2] but the relief is much more long-lasting with microvascular decompression

  • Percutaneous surgeries make sense for older patients with medically unresponsive trigeminal neuralgia

  • Younger patients and those expected to do well under general anesthesia should first consider microvascular decompression

See Treatment and Medication for more detail.


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