What are the treatment options for Trigeminal Neuralgia?

From the Guidelines

Trigeminal neuralgia should be treated with carbamazepine as the first-line agent, starting at 200 mg at night and gradually increasing by 200 mg every 7 days to a final dose of 400–1200 mg, divided in 2–3 doses per day, as it has been shown to provide significant pain relief in 70% of patients 1. The treatment of trigeminal neuralgia typically involves medications, with anticonvulsants being the primary choice.

• Carbamazepine is the most commonly used medication, with a recommended starting dose of 200 mg at night, gradually increasing to 400-1200 mg per day, divided into 2-3 doses, as needed 1.
• Alternative medications include oxcarbazepine, gabapentin, and pregabalin, which can be used if carbamazepine is not effective or causes intolerable side effects 1.
• Surgical options, such as microvascular decompression, stereotactic radiosurgery, and percutaneous procedures, may be considered if medications are not effective or cause significant side effects 1.
• During acute attacks, patients should avoid triggers like cold air, chewing, or touching the face, and applying warm compresses may provide temporary relief.
• Regular follow-up is essential to monitor medication effectiveness and adjust treatment as needed, with consideration of combination therapy or referral to a neurologist or neurosurgeon if first-line medications fail or cause intolerable side effects.

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

• Initial dose: 100 mg twice a day (200 mg/day)
• Dose adjustment: Increase by up to 200 mg/day in 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, with some patients requiring as little as 200 mg daily or as much as 1200 mg daily 2

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, 4, 5, 6.
• Oxcarbazepine is also considered a first-line treatment and may be used as an alternative to carbamazepine 3, 4, 6.
• Other medications that may be used as add-on therapy or as alternatives include lamotrigine, gabapentin, pregabalin, baclofen, and botulinum toxin type A 3, 7, 4, 6.
• Surgical options may be considered if medical treatment is ineffective or poorly tolerated, including microvascular decompression, stereotactic radiation therapy, percutaneous balloon micro compression, percutaneous glycerol rhizolysis, and percutaneous radiofrequency rhizotomy 3, 5, 6.

Pharmacological Treatment

• The mechanism of action of carbamazepine and oxcarbazepine involves modulation of voltage-gated sodium channels, leading to a decrease in neuronal activity 4.
• New pharmacological alternatives are being explored, including eslicarbazepine and vixotrigine, although their efficacy and safety for trigeminal neuralgia are still being investigated 7, 4.
• Combination therapy may be an effective approach, allowing for lower doses of individual medications and reducing the risk of adverse events, but requires careful consideration of potential pharmacokinetic interactions 7.

Surgical Intervention

• Microvascular decompression is considered the first-line surgical treatment for patients with trigeminal neurovascular conflict 3, 5, 6.
• Other surgical options, such as neuroablative surgical treatments, may be considered for patients who are not suitable for microvascular decompression or have not responded to medical treatment 3, 5, 6.