What is the recommended treatment for trigeminal neuralgia?

From the Guidelines

The recommended treatment for trigeminal neuralgia is carbamazepine, which should be offered as a first-line agent for pain control, as it has been shown to provide partial or complete pain relief in 70% of patients. This recommendation is based on a systematic review of four placebo-controlled studies, including a total of 147 patients, treated with 300–2400 mg/day of carbamazepine 1. The dose of carbamazepine can 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.

Some key points to consider when treating trigeminal neuralgia include:

• The clinical features of trigeminal neuralgia, which is defined by the IASP as ‘a sudden usually unilateral severe brief stabbing recurrent episodes of pain in the distribution of one or more branches of the trigeminal nerve’ 1
• The potential side effects of carbamazepine, which include drowsiness, headache, and dizziness 1
• The importance of regular monitoring for medication side effects, particularly for carbamazepine, which requires blood count and liver function monitoring
• The consideration of alternative first-line medications, such as oxcarbazepine, which has been shown to be equally effective with fewer side effects 1
• The potential for surgical interventions, including microvascular decompression, stereotactic radiosurgery, or percutaneous procedures, for patients who do not respond adequately to medication or experience intolerable side effects 1

In terms of surgical options, microvascular decompression has been shown to provide the best rates of long-term complete pain relief and preservation of facial sensation, but it is a major neurosurgical procedure with attendant risks 1. Ablative techniques, such as radiofrequency thermocoagulation, glycerol rhizolysis, balloon compression, or posterior fossa partial sensory rhizotomy, can provide immediate relief of pain in most patients, but have a higher rate of facial sensory loss, trigeminal motor dysfunction, and pain recurrence 1. Stereotactic radiosurgery is an ablative procedure that has been shown to be effective in treating trigeminal neuralgia, but the quality of the literature is generally poor, and more high-quality studies are needed to fully evaluate its efficacy 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 Carbamazepine tablets are indicated in the treatment of the pain associated with true trigeminal neuralgia.

The recommended treatment for trigeminal neuralgia is carbamazepine. The initial dose is 100 mg twice a day, with a total daily dose of 200 mg, which can be increased by up to 200 mg/day as needed to achieve freedom from pain, not exceeding 1200 mg daily. Maintenance dose can be as low as 200 mg daily or as high as 1200 mg daily, with most patients requiring 400 to 800 mg daily 2.

From the Research

Treatment Options for Trigeminal Neuralgia

The treatment for trigeminal neuralgia can be divided into medical and surgical options.

• Medical treatment is the first line of treatment, with carbamazepine and oxcarbazepine being the most commonly used drugs 3, 4, 5.
• These drugs are effective in reducing pain intensity and the number of pain crises, with carbamazepine being the mainstay of pharmacotherapy 4.
• Other drugs such as lamotrigine, baclofen, gabapentin, pregabalin, and botulinum toxin-A can be used as alternative or adjunctive treatments 3, 4, 5.
• Surgical options are available for patients who do not respond to medical treatment or have intolerable side effects, with microvascular decompression, gamma knife radiosurgery, and percutaneous rhizotomies being the most promising alternatives 3.

Pharmacological Treatment

Pharmacological treatment is the primary approach for managing trigeminal neuralgia, with the goal of reducing pain intensity and improving quality of life.

• The antiepileptic drugs carbamazepine and oxcarbazepine are the first-line pharmacological treatment, with a mechanism of action that modulates voltage-gated sodium channels 5.
• Other anticonvulsants such as gabapentin, pregabalin, lamotrigine, and phenytoin can be used as alternative or adjunctive treatments 4, 5.
• The association between carbamazepine and peripheral analgesic block with ropivacaine has been shown to be effective in reducing pain intensity and daily drug intake 6.

Surgical Treatment

Surgical treatment is considered for patients who do not respond to medical treatment or have intolerable side effects.

• Microvascular decompression is a surgical procedure that involves relieving the compression of the trigeminal nerve by a blood vessel, and is considered a highly effective treatment option 3, 7.
• Gamma knife radiosurgery and percutaneous rhizotomies are other surgical options available for the treatment of trigeminal neuralgia 3.
• The choice of surgical treatment depends on the individual patient's condition, age, and medical history, as well as the severity of their symptoms 7.