What is the diagnosis and treatment for trigeminal neuralgia?

From the Guidelines

Trigeminal neuralgia should be treated with carbamazepine as the first-line agent, starting at 200 mg at night and gradually increasing by 200 mg every 7 days to a final dose of 400–1200 mg, divided into 2–3 doses per day, as it has been shown to provide significant pain relief in 70% of patients 1. The condition is characterized by sudden, severe, and brief episodes of pain in the distribution of one or more branches of the trigeminal nerve, typically triggered by everyday activities like eating, talking, or brushing teeth. Some key points to consider in the management of trigeminal neuralgia include:

• The use of anticonvulsant medications, such as carbamazepine, oxcarbazepine, gabapentin, or pregabalin, as first-line treatment options 1
• The importance of gradual dose escalation and regular follow-ups to adjust treatment as needed and minimize side effects
• The consideration of surgical options, including microvascular decompression, stereotactic radiosurgery, or ablative procedures, for patients who do not respond to medical treatment or experience intolerable side effects 1
• The need for patients to avoid known triggers and maintain regular follow-ups with their healthcare provider to optimize treatment outcomes.

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. Key Points:

• The initial dose 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.
• The maximum daily dose should not exceed 1200 mg.
• Maintenance doses typically range from 400 to 800 mg daily, but can be as low as 200 mg or as high as 1200 mg daily. 2

From the Research

Definition and Diagnosis 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.
• 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.

Treatment Options for Trigeminal Neuralgia

• Carbamazepine and oxcarbazepine are the drugs of first choice for treating TN 3, 4.
• Other treatment options include lamotrigine, gabapentin, pregabalin, botulinum toxin type A, and baclofen, which can be used either alone or as add-on therapy 3.
• Oxcarbazepine has been shown to be effective in patients with TN who are unresponsive to carbamazepine 5, 6.
• Surgery should be considered if the pain is poorly controlled or the medical treatments are poorly tolerated 3.
• Trigeminal microvascular decompression is the first-line surgery in patients with trigeminal neurovascular conflict, while 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.

Pharmacological Treatment and Future Perspectives

• Unique among neuropathic pain conditions, TN frequently has an excellent response to some selected drugs, which often entail disabling side effects 4.
• Sodium channel blockers selective for the sodium channel 1.7 (Nav1.7) receptor, currently under development, might be an alternative, better-tolerated pharmacological option in the future 4.
• Third-generation anticonvulsants, new calcitonin gene-related peptide blockers for migraine, and older drugs such as ketamine and cannabinoids may be promising adjuvants or monotherapeutic options 7.
• Combination therapy might allow for lower doses of carbamazepine or oxcarbazepine, thus reducing the number and severity of potential adverse events, but the potential for pharmacokinetic drug-drug interactions must be considered 7.