What are the treatment options for Trigeminal Neuralgia (TN)?

From the Guidelines

Trigeminal neuralgia treatment should begin with anticonvulsant medications, specifically carbamazepine (Tegretol), as the first-line option, due to its efficacy in providing pain relief, as demonstrated in a systematic review of four placebo-controlled studies 1. The treatment of trigeminal neuralgia (TN) typically involves a multidisciplinary approach, with medications being the initial line of treatment.

• The first-line medication for TN is carbamazepine (Tegretol), which is a sodium channel-blocker that has been shown to be effective in providing pain relief in 70% of patients 1.
• The dosage 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 1.
• Alternative medications, such as oxcarbazepine (Trileptal), can be used in patients who do not respond to carbamazepine or experience intolerable side effects, as it has been shown to be equally effective with fewer side effects 1.
• Other medications, such as lamotrigine, baclofen, and gabapentin, can also be used as adjunctive therapy in patients who do not respond adequately to first-line treatment 1. If medications fail or cause intolerable side effects, surgical options can be considered, including:
• Microvascular decompression, which is a non-ablative procedure that involves separating blood vessels from the trigeminal nerve, and has been shown to provide long-term complete pain relief in 70% of patients 1.
• Stereotactic radiosurgery (Gamma Knife), which is an ablative procedure that uses radiation to damage the trigeminal nerve, and has been shown to be effective in providing pain relief in patients with TN 1.
• Percutaneous procedures, such as glycerol injection or balloon compression, which are also ablative procedures that can provide immediate relief of pain in most patients, but may result in facial sensory loss or other complications 1. It is essential to note that the choice of treatment should be individualized based on the patient's specific needs and medical history, and that a neurosurgical opinion should be obtained at an early stage to discuss the available treatment options and determine the best course of treatment 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 treatment option for Trigeminal Neuralgia (TN) is carbamazepine. The initial dose is 100 mg twice a day, with a possible increase of up to 200 mg/day as needed to achieve freedom from pain, not exceeding 1200 mg daily. Maintenance dose can range from 200 mg daily to 1200 mg daily, with most patients requiring 400 to 800 mg daily 2.

From the Research

Treatment Options for Trigeminal Neuralgia

The treatment options for Trigeminal Neuralgia (TN) can be categorized into medical and surgical treatments.

• Medical treatments include:
  • First-line therapy: carbamazepine and oxcarbazepine 3, 4, 5, 6, 7
  • Second-line treatments: lamotrigine and baclofen 3, 5
  • Alternative treatments: topiramate, levetiracetam, gabapentin, pregabalin, and botulinum toxin-A 3, 5
• Surgical options are available if medications are no longer effective or tolerated, and include:
  • Microvascular decompression 3, 4, 6
  • Gamma knife radiosurgery 3
  • Percutaneous rhizotomies 3, 4

Pharmacological Treatments

Pharmacological treatments for TN aim to reduce pain intensity and frequency.

• The antiepileptic drugs carbamazepine and oxcarbazepine are the first-line pharmacological treatment for TN, with a mechanism of action that modulates voltage-gated sodium channels, leading to a decrease in neuronal activity 5
• Other drugs that may be useful for pain control in TN include gabapentin, pregabalin, lamotrigine, phenytoin, baclofen, and botulinum toxin type A 5
• New pharmacological alternatives are being explored, such as eslicarbazepine and vixotrigine 5

Efficacy and Safety of Carbamazepine

Carbamazepine has been widely used as a first-line treatment option for TN, and its safety and efficacy have been evaluated in several studies.

• A meta-analysis of 15 relevant studies found that carbamazepine demonstrated significant efficacy in reducing pain intensity and frequency in patients with TN, and was generally well-tolerated 7
• However, caution should be exercised in patients with certain comorbidities or specific populations, as some rare but severe adverse events were reported 7