What are the symptoms and treatment options for Trigeminal (cranial nerve V) neuralgia?

From the Guidelines

Trigeminal neuralgia is characterized by sudden, severe, electric shock-like pain along the distribution of the trigeminal nerve, typically affecting one side of the face, and treatment begins with anticonvulsant medications, particularly carbamazepine (Tegretol) at 100-200mg twice daily, gradually increased until pain relief occurs or side effects develop (typically 600-1200mg daily) 1.

Symptoms of Trigeminal Neuralgia

• Brief episodes of intense facial pain triggered by activities like eating, talking, brushing teeth, or even light touch
• Pain commonly affects the cheek, jaw, teeth, gums, lips, or less frequently the eye and forehead
• Episodes may last seconds to minutes and can occur multiple times daily, with periods of remission

Treatment Options

• Anticonvulsant medications:
  • Carbamazepine (Tegretol) at 100-200mg twice daily, gradually increased until pain relief occurs or side effects develop (typically 600-1200mg daily) 1
  • Alternatives include oxcarbazepine (Trileptal), gabapentin (Neurontin), pregabalin (Lyrica), or baclofen 1
• Surgical options for medication-resistant cases:
  • Microvascular decompression to relieve pressure on the nerve
  • Stereotactic radiosurgery
  • Various ablative procedures like glycerol injection or radiofrequency ablation 1

Diagnosis and Imaging

• MRI is useful for directly imaging the trigeminal nerve and assessing for neurovascular compression 1
• CT is very useful for evaluating the skull base and neural foramina 1
• Advanced MRI techniques, such as diffusion tensor imaging (DTI) and functional MRI, may be useful in researching the pathophysiology of trigeminal neuralgia 1

From the FDA Drug Label

Carbamazepine tablets are indicated in the treatment of the pain associated with true trigeminal neuralgia. This drug is not a simple analgesic and should not be used for the relief of trivial aches or pains. 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.

The symptoms of trigeminal neuralgia include pain associated with true trigeminal neuralgia. Treatment options for trigeminal neuralgia include carbamazepine, with the following dosing regimen:

• Initial dose: 100 mg twice a day for a total daily dose of 200 mg
• Dose increase: up to 200 mg/day using increments of 100 mg every 12 hours, as needed to achieve freedom from pain
• Maximum daily dose: 1200 mg daily
• Maintenance dose: 400 to 800 mg daily 2 2

From the Research

Symptoms of Trigeminal Neuralgia

• Sudden, brief, and excruciating facial pain attacks in one or more of the V branches (ophthalmic, maxillary, and mandibular) 3
• Severe reduction in the quality of life of affected patients 3
• Pain attacks can be triggered by light touch or other stimuli 3

Treatment Options for Trigeminal Neuralgia

• Antiepileptic drugs carbamazepine and oxcarbazepine are the first-line pharmacological treatment for trigeminal neuralgia 3, 4, 5, 6
• Mechanism of action: modulation of voltage-gated sodium channels, leading to a decrease in neuronal activity 3
• Other drugs that may be useful for pain control in trigeminal neuralgia:
  • Gabapentin 3, 7, 5
  • Pregabalin 3, 7, 5
  • Lamotrigine 3, 5
  • Phenytoin 5
  • Baclofen 3, 7, 5
  • Botulinum toxin type A 3
• 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 4
• New pharmacological alternatives are being explored, such as eslicarbazepine and vixotrigine 3