What is the diagnosis and treatment for Trigeminal Neuralgia?

From the Guidelines

Trigeminal neuralgia should be treated with carbamazepine (CBZ) as the first-line agent for pain control, with a starting dose of 200 mg at night and gradually increased by 200 mg every 7 days to a final dose of 400–1200 mg, divided in 2–3 doses per day, as it has been shown to provide partial or complete pain relief in 70% of patients 1.

Treatment Options

• Anticonvulsant medications, such as carbamazepine, oxcarbazepine, gabapentin, or pregabalin, are the primary treatment for trigeminal neuralgia
• Surgical options, including microvascular decompression, gamma knife radiosurgery, or percutaneous rhizotomy, may be considered for patients who do not respond to medication

Diagnosis and Imaging

• MRI is useful for directly imaging the trigeminal nerve and assessing for neurovascular compression, with 3-D heavily T2-weighted MRI sequences, MRA, and a combination of these techniques being commonly used noninvasive methods 1
• Imaging protocols should use applicable thin-cut high-resolution techniques and pre- and postcontrast imaging to identify and characterize lesions

Patient Management

• Patients should avoid triggers such as touching certain facial areas, exposure to cold, eating, talking, or brushing teeth when possible
• Pain typically affects one side of the face in the distribution of one or more branches of the trigeminal nerve, with the maxillary and mandibular divisions most commonly involved
• The condition results from compression of the trigeminal nerve by blood vessels or, less commonly, from demyelination associated with multiple sclerosis 1

From the FDA Drug Label

Trigeminal Neuralgia(see INDICATIONS AND USAGE) Initial:On the first day, 100 mg twice a day for tablets for a total daily dose of 200 mg This daily dose may be increased by up to 200 mg/day using increments of 100 mg every 12 hours for tablets, only as needed to achieve freedom from pain. Do not exceed 1200 mg daily. Maintenance:Control of pain can be maintained in most patients with 400 to 800 mg daily. However, some patients may be maintained on as little as 200 mg daily, while others may require as much as 1200 mg daily Carbamazepine tablets are indicated in the treatment of the pain associated with true trigeminal neuralgia. The initial dose of carbamazepine for Trigeminal Neuralgia is 100 mg twice a day, with a total daily dose of 200 mg. The dose can be increased by up to 200 mg/day in increments of 100 mg every 12 hours as needed to achieve freedom from pain, not exceeding 1200 mg daily. The maintenance dose to control pain is typically between 400 to 800 mg daily 2. Carbamazepine is indicated for the treatment of pain associated with true trigeminal neuralgia 2.

• Key points:
  • Initial dose: 100 mg twice a day
  • Maximum daily dose: 1200 mg
  • Maintenance dose: 400 to 800 mg daily
  • Indication: Trigeminal Neuralgia

From the Research

Definition and Characteristics of Trigeminal Neuralgia

• Trigeminal neuralgia (TN) is a highly disabling disorder characterized by very severe, brief, and electric shock-like recurrent episodes of facial pain 3.
• It is a painful condition that often leads to poor quality of life 4.
• The trigeminal nerve is responsible for detecting sensory stimuli that arise from the craniofacial area, and TN is characterized by sudden, brief, and excruciating facial pain attacks in one or more of the nerve's branches 5.

Diagnosis and Diagnostic Criteria

• New diagnostic criteria subclassify TN based on the presence of trigeminal neurovascular conflict or an underlying neurological disorder, allowing for better characterization of patients and decision-making regarding medical and surgical treatments 3.
• MR imaging, including high-resolution trigeminal sequences, should be performed as part of the diagnostic work-up 3.

Medical Management and Treatment Options

• Carbamazepine and oxcarbazepine are the drugs of first choice for treating TN 3, 4.
• Alternative drugs that can be used alone or as add-on therapy include lamotrigine, gabapentin, pregabalin, botulinum toxin type A, and baclofen 3, 4, 5.
• Combination therapy may be the optimal approach, allowing for lower doses of carbamazepine or oxcarbazepine and reducing the number and severity of potential adverse events 6.
• Newer drugs, such as vixotrigine, are being explored as potential treatment options 4, 5.

Surgical Options

• Surgery should be considered if the pain is poorly controlled or medical treatments are poorly tolerated 3, 4.
• Trigeminal microvascular decompression is the first-line surgery in patients with trigeminal neurovascular conflict 3.
• Neuroablative surgical treatments can be offered if MR imaging does not show any neurovascular contact or where patients are considered too frail for microvascular decompression or do not wish to take the risk 3.
• Other surgical options, such as radiofrequency thermal rhizotomy, glycerol rhizotomy, balloon compression, partial sensory trigeminal rhizotomy, and peripheral neurectomy, may be considered in certain cases 7.