What is the treatment for trigeminal (nerve) neuralgia?

From the Guidelines

Trigeminal neuralgia treatment should begin with carbamazepine (CBZ) as the first-line agent, given its proven efficacy in achieving pain control with a significant response rate of 70% in patients treated with 300–2400 mg/day, as demonstrated in a systematic review of four placebo-controlled studies 1. The treatment approach for trigeminal neuralgia involves a step-wise strategy, starting with pharmacological management and progressing to surgical interventions if necessary.

• The initial pharmacological treatment typically involves anticonvulsant medications, with carbamazepine (Tegretol) being the primary option, started at a dose of 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, as recommended in the study published in Ophthalmology 1.
• Alternative anticonvulsant medications, such as oxcarbazepine, gabapentin, or pregabalin, may be considered if patients experience inadequate relief or intolerable side effects from carbamazepine, as suggested in the British Journal of Anaesthesia study 1.
• Surgical interventions, including microvascular decompression, gamma knife radiosurgery, or percutaneous procedures like glycerol injection or balloon compression, should be considered for patients with inadequate relief from medications or intolerable side effects, with the goal of reducing pressure on the trigeminal nerve or disrupting pain signals, as discussed in the study published in the British Journal of Anaesthesia 1.
• Pain management should also include avoiding triggers, such as cold air, chewing, or touching specific facial areas, and regular follow-up is essential to monitor medication effectiveness and adjust treatment as needed.
• The treatment selection depends on the patient's age, overall health, and symptom severity, with the goal of achieving pain control while minimizing side effects, as emphasized in the study published in the British Journal of Anaesthesia 1.

From the FDA Drug Label

Carbamazepine tablets are indicated in the treatment of the pain associated with true trigeminal neuralgia. The treatment of trigeminal neuralgia with carbamazepine is supported by the FDA drug label 2.

• Carbamazepine is indicated for the treatment of the pain associated with true trigeminal neuralgia.
• Beneficial results have also been reported in glossopharyngeal neuralgia. The FDA drug label does not provide information on the treatment of original neuralgia, but it does provide information on the treatment of trigeminal neuralgia.

From the Research

Treatment Options for Trigeminal Neuralgia

• The first-line treatment for trigeminal neuralgia is pharmacotherapy, with carbamazepine being the drug of choice 3, 4, 5, 6.
• Alternative pharmacological treatments include gabapentin, pregabalin, lamotrigine, and botulinum toxin type A, which can be used alone or in combination with carbamazepine 4, 5, 6.
• For patients who are intolerant or resistant to pharmacotherapy, interventional or surgical procedures may be necessary, such as microvascular decompression, radiofrequency thermal rhizotomy, or glycerol rhizotomy 3, 4, 7.

Surgical Interventions

• Microvascular decompression is a safe and effective procedure with immediate and durable outcomes, but may not be suitable for patients with medical comorbidities or those who are unable to tolerate general anesthesia 4, 7.
• Percutaneous methodologies, such as glycerol or radiofrequency ablation, may be an alternative for patients who are ineligible for open surgical procedures 4, 7.
• Radiosurgery may be an option for patients who are unwilling to undergo open surgical procedures or have bleeding diathesis due to blood thinning medications 4, 7.

Pharmacological Treatment Considerations

• The benefits of carbamazepine are offset by adverse effects, such as drowsiness, dizziness, rash, bone marrow suppression, and liver dysfunction, which may lead to its withdrawal 6.
• Low-dose titration is important to avoid the development of rashes and adverse effects, particularly with carbamazepine and lamotrigine, which can cause severe drug eruptions such as Stevens-Johnson syndrome and toxic epidermal necrolysis 6.