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

From the Guidelines

Carbamazepine should be offered as the first-line treatment for trigeminal neuralgia, with a starting dose of 200 mg at night and gradually increased by 200 mg every 7 days to a final dose of 400–1200 mg, divided in 2–3 doses per day, due to its proven efficacy in reducing pain frequency and intensity, as demonstrated in a systematic review of four placebo-controlled studies 1.

Treatment Overview

Trigeminal neuralgia treatment typically begins with anticonvulsant medications, with carbamazepine being the primary option. The goal of treatment is to reduce the frequency and intensity of painful episodes, thereby improving the patient's quality of life.

• Carbamazepine works by stabilizing neuronal membranes and reducing abnormal nerve firing, with 70% of patients showing partial or complete pain relief in clinical trials 1.
• The most common side effects of carbamazepine include drowsiness, headache, and dizziness, which can be managed by adjusting the dose or switching to an alternative medication.

Alternative Treatment Options

If carbamazepine is ineffective or poorly tolerated, alternative treatment options include:

• Oxcarbazepine, which is equally effective with fewer side effects, as suggested by international guidelines and Cochrane reviews 1.
• Gabapentin, pregabalin, or baclofen, which have shown efficacy in reducing pain frequency and intensity, although the evidence is limited to a few studies 1.

Surgical Interventions

For patients with inadequate relief from medications or intolerable side effects, surgical interventions should be considered, including:

• Microvascular decompression, which has a 70% chance of being pain-free at 10 years, although it is a major neurosurgical procedure with potential complications such as hearing loss and mortality 1.
• Gamma knife radiosurgery or percutaneous procedures like glycerol injection or balloon compression, which can provide relief for patients who are not candidates for microvascular decompression or have failed other treatments 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

• Treatment of Trigeminal Neuralgia: The initial dose of carbamazepine is 100 mg twice a day, with a total daily dose of 200 mg. The dose can be increased by up to 200 mg/day in increments of 100 mg every 12 hours as needed to achieve freedom from pain, not exceeding 1200 mg daily.
• Maintenance Dose: The maintenance dose to control pain can be as low as 200 mg daily or as high as 1200 mg daily, but most patients are maintained on 400 to 800 mg daily 2.

From the Research

Treatment Options for Trigeminal Neuralgia

• Medical treatments:
  • Carbamazepine and oxcarbazepine are considered first-line treatments for trigeminal neuralgia 3, 4, 5
  • Other medications that can be used alone or as add-on therapy include lamotrigine, gabapentin, pregabalin, botulinum toxin type A, and baclofen 3
  • Combination therapy may be an optimal approach, allowing for lower doses of carbamazepine or oxcarbazepine and reducing potential adverse events 4
• Surgical treatments:
  • Trigeminal microvascular decompression is considered the first-line surgery for patients with trigeminal neurovascular conflict 3
  • Neuroablative surgical treatments can be offered if MR imaging does not show any neurovascular contact or if patients are considered too frail for microvascular decompression or do not wish to take the risk 3
  • Other surgical options include destructive neurosurgical techniques such as radiofrequency thermocoagulation, glycerol rhizolysis, balloon compression, and stereotactic radiosurgery 6, 7

Effectiveness and Tolerability of Treatments

• Carbamazepine and oxcarbazepine are highly effective in the long-term treatment of trigeminal neuralgia, but their tolerability can be a major issue, particularly in patients with secondary and idiopathic trigeminal neuralgia 5
• The frequency of side effects is higher with carbamazepine than with oxcarbazepine, and treatment discontinuation is more common in patients with secondary and idiopathic forms of the condition 5
• The development of better-tolerated drugs is necessary to improve treatment outcomes for patients with trigeminal neuralgia 5

Diagnostic Criteria and Imaging

• New diagnostic criteria for trigeminal neuralgia subclassify the condition based on the presence of trigeminal neurovascular conflict or an underlying neurological disorder, allowing for better characterization of patients and decision-making regarding medical and surgical treatments 3
• MR imaging, including high-resolution trigeminal sequences, should be performed as part of the diagnostic work-up for trigeminal neuralgia 3