What is the current management of Trigeminal Neuralgia (TN)?

From the Guidelines

The current management of trigeminal neuralgia typically begins with medication, primarily carbamazepine, as the first-line treatment, due to its efficacy in blocking sodium channels and reducing the abnormal firing of trigeminal nerve fibers responsible for the pain, as supported by a systematic review that concluded CBZ should be offered as a first-line agent for pain control in TGN (level A) 1. The treatment approach involves starting with a low dose of 200 mg at night and gradually increasing by 200 mg every 7 days to a final dose of 400–1200 mg, divided in 2–3 doses per day, as needed for pain control, with the goal of achieving pain relief while minimizing side effects such as drowsiness, headache, and dizziness 1. Some key points to consider in the management of trigeminal neuralgia include:

• The importance of prompt treatment to minimize the impact on quality of life
• The need for regular follow-ups to monitor treatment effectiveness and adjust the regimen as necessary
• The consideration of surgical options, such as microvascular decompression or ablative procedures like radiofrequency thermocoagulation or gamma knife radiosurgery, for patients who do not respond to or cannot tolerate medication, as suggested by international guidelines and Cochrane reviews 1
• The potential for variants of trigeminal neuralgia, such as type 2, which may require different management approaches
• The importance of obtaining a neurosurgical opinion at an early stage for patients who may require surgical intervention, with microvascular decompression offering a 70% chance of being pain-free at 10 years, although it is a major neurosurgical procedure with potential complications such as hearing loss and mortality 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

• The current management of Trigeminal Neuralgia (TN) involves the use of carbamazepine.
• The initial dose 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.
• Maintenance doses typically range from 200 to 1200 mg daily, with most patients requiring 400 to 800 mg daily 2.

From the Research

Current Management of Trigeminal Neuralgia

The current management of Trigeminal Neuralgia (TN) involves several options, including:

• Pharmacotherapy: This is the first line of treatment, with carbamazepine being the most commonly used drug 3, 4, 5, 6.
• Destructive procedures: These include non-surgical methods such as injections along trigeminal pathways, percutaneous trigeminal radiofrequency thermocoagulation, and surgical methods such as trigeminal branch avulsion or peripheral neurectomy, avulsion of trigeminal nerve, trigeminal tractotomy, and radiosurgery 3.
• Non-destructive procedures: These include microvascular decompression 3 and other surgical options 4.

Pharmacotherapy Options

Pharmacotherapy options for TN include:

• Monotherapy with one anticonvulsant, such as carbamazepine or oxcarbazepine 3, 5, 6.
• Combined therapy with more than one anticonvulsant, such as carbamazepine and lamotrigine or baclofen 5.
• Add-on therapy with newer drugs, such as third-generation anticonvulsants, calcitonin gene-related peptide blockers, and older drugs like ketamine and cannabinoids 7.
• Polytherapy with anticonvulsant + add-on drugs + antidepressants/anxiolytics 3.

Surgical Options

Surgical options for TN include:

• Open surgery 4.
• Minimally invasive percutaneous techniques 4.
• Microvascular decompression 3.
• Radiosurgery 3.

Treatment Approach

The treatment approach for TN typically involves:

• Initial treatment with pharmacotherapy, usually carbamazepine 3, 4, 5, 6.
• Consideration of surgical options when medical treatment fails 4.
• Early neurosurgical opinion for patients with neurovascular contact of the trigeminal nerve, poor efficacy and tolerability of drug treatment, and no remission periods 5.