What is the best treatment for Trigeminal Neuralgia (TN)?

From the Guidelines

The best treatment for trigeminal neuralgia typically begins with anticonvulsant medications, with carbamazepine being the first-line option, as suggested by international guidelines and Cochrane reviews 1. When considering treatment options, it's essential to prioritize medications that have been shown to be effective in managing trigeminal neuralgia.

• Carbamazepine (Tegretol) is usually the first choice, starting at 100-200mg twice daily and gradually increasing to 200-400mg three times daily as needed.
• Oxcarbazepine (Trileptal) is an effective alternative with fewer side effects, typically starting at 300mg twice daily and increasing as needed, as it has been found to be equally effective with fewer side effects 1. If these medications are ineffective or poorly tolerated, second-line options include:
• Gabapentin (300-1200mg three times daily)
• Pregabalin (150-300mg twice daily)
• Baclofen (10-25mg three times daily) For patients who don't respond adequately to medication, surgical interventions may be considered, including:
• Microvascular decompression (which addresses blood vessel compression of the trigeminal nerve)
• Gamma knife radiosurgery
• Percutaneous procedures like glycerol injection or balloon compression These treatments work by either reducing abnormal nerve firing or addressing the underlying compression of the trigeminal nerve by blood vessels, which is believed to be the cause in many cases 1. During painful episodes, patients should avoid triggers like touching the face, exposure to cold air, or certain foods, and may benefit from applying warm compresses to the affected area. It's also important to note that a neurosurgical opinion should be obtained at an early stage, as surgical interventions can be effective in managing trigeminal neuralgia, with microvascular decompression offering a 70% chance of being pain-free at 10 years 1.

From the FDA Drug Label

CLINICAL PHARMACOLOGY In controlled clinical trials, carbamazepine has been shown to be effective in the treatment of psychomotor and grand mal seizures, as well as trigeminal neuralgia. Trigeminal Neuralgia Carbamazepine tablets are indicated in the treatment of the pain associated with true trigeminal neuralgia.

The best treatment for trigeminal neuralgia is carbamazepine (PO), as it has been shown to be effective in controlled clinical trials and is indicated for the treatment of the pain associated with true trigeminal neuralgia 2 2.

• Key points:
  • Carbamazepine has been shown to be effective in treating trigeminal neuralgia
  • It is indicated for the treatment of the pain associated with true trigeminal neuralgia
  • It is not a simple analgesic and should not be used for the relief of trivial aches or pains

From the Research

Treatment Options for Trigeminal Neuralgia

• The primary treatment for trigeminal neuralgia includes carbamazepine and oxcarbazepine, which are effective in most patients 3, 4, 5, 6, 7.
• However, these drugs can have dose-dependent and potentially treatment-limiting adverse effects, leading to the need for alternative options 3, 6, 7.
• Other potential treatment options include:
  • Third-generation anticonvulsants 3
  • New calcitonin gene-related peptide blockers for migraine 3
  • Ketamine and cannabinoids as adjuvants or monotherapeutic options 3
  • Lamotrigine, gabapentin, pregabalin, botulinum toxin type A, and baclofen as add-on therapy or alone 4
• Surgical options, such as microvascular decompression, stereotactic radiation therapy, percutaneous balloon micro compression, percutaneous glycerol rhizolysis, and percutaneous radiofrequency, may be considered if pharmacological treatment fails 4, 5.
• Combination therapy, using multiple agents, may be an optimal approach to reduce the number and severity of potential adverse events, but requires consideration of pharmacokinetic drug-drug interactions 3.

Efficacy and Tolerability of Carbamazepine and Oxcarbazepine

• Carbamazepine and oxcarbazepine have been shown to be highly effective in the long-term treatment of trigeminal neuralgia, with initial response rates of 88.3% and 90.9%, respectively 6.
• However, side effects are a major issue, with 43.6% of patients treated with carbamazepine and 30.3% of patients treated with oxcarbazepine experiencing side effects 6.
• The frequency of treatment discontinuation is higher in patients with secondary and idiopathic forms of trigeminal neuralgia compared to those with classical trigeminal neuralgia 6.

Future Perspectives

• The development of better-tolerated drugs, such as sodium channel blockers selective for the sodium channel 1.7 (Nav1.7) receptor, may provide alternative treatment options for trigeminal neuralgia in the future 7.