What is the treatment for trigeminal neuralgia?

From the Guidelines

Trigeminal neuralgia is best treated with carbamazepine as the first-line medication, starting at 200 mg at night and gradually increasing to 400-1200 mg daily, as it has been shown to provide significant pain relief in 70% of patients 1. The treatment of trigeminal neuralgia involves a combination of medications and potentially surgical interventions if medications fail.

• The first-line medication treatment is carbamazepine (Tegretol), which is a sodium channel-blocker that works by stabilizing neuronal membranes and reducing the abnormal firing of the trigeminal nerve.
• The dosage of carbamazepine should be started at 200 mg at night and gradually increased by 200 mg every 7 days to a final dose of 400-1200 mg, divided into 2-3 doses per day 1.
• Oxcarbazepine (Trileptal) is an alternative option, which can be started at 300 mg twice daily, increasing to 600-1200 mg twice daily 1.
• If these medications are ineffective or poorly tolerated, second-line options include baclofen (10-25 mg three times daily), gabapentin (300-1200 mg three times daily), or pregabalin (150-300 mg twice daily) 1.
• For patients with refractory pain, surgical options include microvascular decompression, which addresses blood vessel compression of the trigeminal nerve, or less invasive procedures like gamma knife radiosurgery, glycerol injections, or balloon compression 1.
• During painful episodes, patients should avoid triggers such as cold air, chewing, or touching the face, and may benefit from applying warm compresses to the affected area.
• Regular follow-up is essential to monitor medication effectiveness and side effects, with blood tests needed for patients on carbamazepine to check liver function and blood counts.

From the FDA Drug Label

Trigeminal Neuralgia Carbamazepine tablets are indicated in the treatment of the pain associated with true trigeminal neuralgia. Beneficial results have also been reported in glossopharyngeal neuralgia. This drug is not a simple analgesic and should not be used for the relief of trivial aches or pains.

Treatment of Trigeminal Neuralgia:

• Carbamazepine is indicated for the treatment of pain associated with true trigeminal neuralgia 2.
• The drug has shown beneficial results in treating glossopharyngeal neuralgia.
• It is essential to note that carbamazepine is not a simple analgesic and should only be used for treating trigeminal neuralgia, not for relief of trivial aches or pains.

From the Research

Treatment Options for Trigeminal Neuralgia

• Medical treatment is the initial approach for trigeminal neuralgia, with carbamazepine being the drug of choice 3
• Oxcarbazepine is also effective and may be used as an alternative to carbamazepine, especially in patients who are intolerant to carbamazepine 4, 3
• Other medications that may be used to treat trigeminal neuralgia include phenytoin, baclofen, clonazepam, and sodium valproate 3
• Newer agents such as lamotrigine and gabapentin are also being tried, but their comparative value has not been established 3
• Combination therapy may be used to allow for lower doses of carbamazepine or oxcarbazepine, reducing the risk of adverse events 5

Pharmacological Treatment

• Carbamazepine and oxcarbazepine are the reference standard drugs for treating patients with trigeminal neuralgia 6
• These drugs are effective in most patients, but may cause disabling side effects, leading to treatment withdrawal or dosage reduction 6
• Sodium channel blockers selective for the sodium channel 1.7 (Nav1.7) receptor are being developed as a potential alternative to carbamazepine and oxcarbazepine 6
• Real-world studies have shown that carbamazepine and oxcarbazepine are effective in most patients with trigeminal neuralgia, but side effects are still a major issue, particularly in patients with secondary and idiopathic trigeminal neuralgia 7

Surgical and Interventional Procedures

• For patients who are resistant to or intolerant of drug therapy, interventional or surgical procedures may be necessary 3
• Microvascular decompression is recommended for younger, fit patients, particularly with involvement of the first division or all three divisions of the nerve 3
• Radiofrequency thermal rhizotomy is probably the next treatment of choice for older patients or those not willing to undergo craniectomy 3
• Other techniques that may be considered include glycerol rhizotomy, balloon compression, partial sensory trigeminal rhizotomy, and peripheral neurectomy 3
• Stereotactic radiosurgery is still being evaluated for the treatment of trigeminal neuralgia, but may become a treatment option for elderly frail patients if longer-term follow-up establishes its continuing benefit 3