How do you diagnose and treat trigeminal neuralgia?

From the Guidelines

Trigeminal neuralgia is diagnosed through a detailed medical history, neurological examination, and imaging studies like MRI to rule out structural causes such as tumors or multiple sclerosis, and treatment begins with anticonvulsant medications, with carbamazepine as first-line therapy. The diagnosis primarily relies on the characteristic symptoms: brief episodes of severe, electric shock-like facial pain triggered by light touch, eating, talking, or brushing teeth, typically affecting one side of the face along the distribution of the trigeminal nerve 1.

Diagnosis

• A detailed medical history to identify the characteristic symptoms of trigeminal neuralgia
• Neurological examination to assess for any sensory or motor deficits
• Imaging studies like MRI to rule out structural causes such as tumors or multiple sclerosis 1

Treatment

• Anticonvulsant medications, with carbamazepine (Tegretol) as first-line therapy starting at 100-200mg twice daily and gradually increasing to 200-400mg three times daily as needed 1
• Alternative medications include oxcarbazepine (300-600mg twice daily), gabapentin (300-1200mg three times daily), pregabalin (75-150mg twice daily), or baclofen (5-25mg three times daily) 1
• If medications fail or cause intolerable side effects, surgical options include microvascular decompression (separating blood vessels from the nerve), stereotactic radiosurgery (Gamma Knife), or percutaneous procedures like glycerol injection, balloon compression, or radiofrequency ablation 1

Surgical Options

• Microvascular decompression: a non-ablative procedure that separates blood vessels from the nerve, with a 70% chance of being pain-free at 10 years 1
• Stereotactic radiosurgery (Gamma Knife): an ablative procedure that uses radiation to damage the nerve and relieve pain 1
• Percutaneous procedures: ablative procedures that use chemicals or heat to damage the nerve and relieve pain 1

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.

The diagnosis of trigeminal neuralgia is not explicitly described in the provided drug labels. However, carbamazepine is indicated for the treatment of the pain associated with true trigeminal neuralgia 2. Key points for treatment include:

• Carbamazepine is not a simple analgesic and should not be used for the relief of trivial aches or pains.
• Beneficial results have also been reported in glossopharyngeal neuralgia. No conclusion can be drawn regarding the diagnosis of trigeminal neuralgia, as the FDA label does not explicitly address this question.

From the Research

Diagnosis of Trigeminal Neuralgia

• Trigeminal neuralgia is defined as sudden, usually unilateral, severe, brief, stabbing recurrent episodes of pain within the distribution of one or more branches of the trigeminal nerve 3
• The diagnosis is made on history alone, and time needs to be taken to elicit the key features and differentiate from toothache or one of the trigeminal autonomic cephalalgias 3
• Magnetic resonance imaging (MRI) should be performed as part of the work-up in TN patients, because no clinical characteristics can exclude secondary TN 4

Treatment of Trigeminal Neuralgia

• Carbamazepine and oxcarbazepine are the first-line drugs for the treatment of trigeminal neuralgia 3, 5, 4
• Other drugs that may be useful for pain control in trigeminal neuralgia include gabapentin, pregabalin, lamotrigine, phenytoin, baclofen, and botulinum toxin type A 5, 4, 6
• Surgical procedures, such as microvascular decompression (MVD) and ablative procedures, may be considered if there is a decrease in efficacy or tolerability of medication 3, 4
• MVD is recommended as first-line surgery in patients with classical TN, while ablative procedures may be preferred if MRI does not demonstrate any neurovascular contact 4

Management of Trigeminal Neuralgia

• An interdisciplinary approach, including adequate pain characterization and collaboration between different specialties, is essential for the diagnosis and treatment of trigeminal neuralgia 7
• Patient support groups can provide information and support to those in pain and play a crucial role in the management of trigeminal neuralgia 3
• Psychological and nursing support should also be offered to patients with trigeminal neuralgia, in addition to medical and surgical management 4