eMedicine Specialties > Ophthalmology > Neurologic Disorders
Trigeminal Neuralgia: Treatment & Medication
Updated: Mar 17, 2006
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
Treatment can be subdivided into pharmacologic therapy, percutaneous procedures, surgery, and radiation therapy. Adequate pharmacologic trials should always precede the contemplation of a more invasive approach. Most patients respond well to initial therapy, but some are resistant to any type of treatment. Treatment must be tailored individually, based on the patient's age and general condition. In the case of secondary trigeminal neuralgia, adequate treatment is that of its cause, the detail of which is out of the scope of this article.
- Carbamazepine (Tegretol, Carbatrol) was introduced in the 1960s and has proven its efficacy in numerous studies. It remains the criterion standard of treatment for this condition.
- Phenytoin (Dilantin) has a lower rate of success, but a patient occasionally responds to it and not to carbamazepine. The dose varies greatly among patients.
- Baclofen has shown its efficacy in the literature.
- Clonazepam (Klonopin) has moderate efficacy but is not recommended because of its adverse effects (eg, sedation) and dependence.
- Amitriptyline (Elavil) can be tried, but the success rate is low.
- Gabapentin (Neurontin) seems to be effective, but as of yet no controlled study is available.
- Lamotrigine (Lamictal) has been proven more effective than placebo. The dosage should be increased slowly for better tolerance (eg, 25 mg daily dose each week; up to 250 mg twice a day).
Surgical Care
The success rate varies according to the experience of the surgeon or the anesthesiologist and, therefore, should be performed only by experienced surgeons. Surgical therapy can be divided into external or percutaneous procedures (usually performed by pain management specialists) and open skull surgery (also called microvascular decompression). The latter has an overall better success rate, but the former may be more cost-effective. The former may also be more accessible to elderly patients who are at high surgical risk.
- Jannetta pioneered microvascular decompression (MVD). This procedure consists of opening a keyhole in the mastoid area and freeing the trigeminal nerve from the compression/pulsating artery; then, a piece of Teflon is placed between them. Large series have been published, and the initial efficacy is more than 80%. Recurrence rates are among the lowest compared with other invasive treatments. Usually, it requires the demonstration of true contact and compression by the artery on the nerve, but series are published that show an almost equally effective result without any demonstrated abnormality on imaging or even frank compression shown preoperatively. See Image 3.
- Alcohol injection of the trigeminus can be performed at various locations along the nerve and is aimed at destroying selective pain fibers. Although it is an easy procedure, the success rate is low, in part because of a low selectivity of effect on the fiber type with this substance.
- Glycerol injection of the gasserian ganglion to selectively destroy the pain-transmitting fibers has been used for a long time. This injection has a higher efficacy rate and a lower recurrence rate than the alcohol injection. It is easy to perform, and anesthesia is not needed.
- Percutaneous radiofrequency rhizotomy and percutaneous microcompression with balloon inflation are relatively inexpensive accessible techniques and less invasive than surgery, with a lower (long-term) efficacy-to-recurrence ratio. The result is highly dependent on the surgeon's skill. General anesthesia is required.
- Recently introduced, gamma-knife treatment consists of multiple rays (over 200) of high-energy photons concentrated with high accuracy on the target (ie, trigeminal nerve root). This treatment destroys specific components of the nerve. Of those treated, 60% of patients are pain-free immediately, and more than 75% of patients have greater than 50% relief after 1.5 years. This treatment can be used after a patient's failure to respond to any of the above-mentioned procedures, including this one. The device contains a stable source of radiation (60-Co) that frees this technique from requiring an external source of radioactivity (eg, cyclotron). See Image 2.
- Pulsed radiofrequency on the trigeminal ganglion appears promising in reports. Likewise, linear-accelerated particle radiation appears to be a valid alternative.
Diet
No specific diet is recommended.
Activity
Other than avoiding the triggers, the activity of the patient should remain normal.
Medication
Treatment of trigeminal neuralgia is prophylactic. Indeed no abortive therapy could be conceived for this very short-lived pain condition. Carbamazepine remains the criterion standard, but a number of other drugs have been used for a long time and with fair success. They should be considered successively in case of resistance. Rarely, combination therapy can be provided, but it should remain exceptional for tolerance reasons and because a synergistic effect rarely occurs. Duration of treatment depends on clinical evolution but usually is long-term, often lasting years. Refer to Physician's Desk Reference (PDR) for details on medications mentioned.
Anticonvulsants
Reduce firing of nerve potentials in the trigeminal nerve.
Carbamazepine (Tegretol, Carbatrol)
Criterion standard in the medical management of trigeminal neuralgia, its efficacy has been demonstrated in multiple clinical trials. As of yet, a controlled trial has not occurred on oxcarbazepine (Trileptal), another carbamate close to carbamazepine. Slow-release forms now available allow a bid dosage. Titrating slowly improves tolerance.
Adult
200 mg PO tid (range 400-1600 mg/d, fractionated over the day); titrate slowly by 200 mg q3d
Pediatric
Not established
Serum levels may increase significantly within 30 d of danazol coadministration (avoid whenever possible); do not coadminister with MAOIs; cimetidine may increase toxicity, especially if taken in first 4 wk of therapy; carbamazepine may decrease primidone and phenobarbital levels (coadministration may increase carbamazepine levels)
Documented hypersensitivity; history of bone marrow depression; administration of MAOIs within last 14 d
Pregnancy
D - Unsafe in pregnancy
Precautions
Most frequent adverse effects are dizziness, ataxia, diplopia, hyponatremia, vertigo, sedation, and skin rash (rare); all are dose dependent; bone marrow suppression is rare but necessitates monitoring; monitor CBC (bone marrow suppression) and sodium (hyponatremia) levels monthly for at least 3 mo; monitor blood levels in case of toxicity or suspected noncompliance but not as routine; because of an autoinduction of its metabolism, carbamazepine levels tend to decrease after a few weeks of treatment, and dosage may need to be adjusted
Phenytoin (Dilantin)
Not as efficient as carbamazepine; use is based on same potential mechanisms.
Adult
300 mg PO qhs (range 100-400 mg/d qd/bid)
Pediatric
Not established
Amiodarone, benzodiazepines, chloramphenicol, cimetidine, fluconazole, isoniazid, metronidazole, miconazole, phenylbutazone, succinimides, sulfonamides, omeprazole, phenacemide, disulfiram, ethanol (acute ingestion), trimethoprim, and valproic acid may increase phenytoin toxicity; phenytoin effects may decrease when taken concurrently with barbiturates, diazoxide, ethanol (chronic ingestion), rifampin, antacids, charcoal, carbamazepine, theophylline, and sucralfate; phenytoin may decrease effects of acetaminophen, corticosteroids, dicumarol, disopyramide, doxycycline, estrogens, haloperidol, amiodarone, carbamazepine, cardiac glycosides, quinidine, theophylline, methadone, metyrapone, mexiletine, oral contraceptives, and valproic acid
Documented hypersensitivity
Pregnancy
D - Unsafe in pregnancy
Precautions
Monitor blood levels in case of potential toxicity but not as routine; adverse effects are dizziness, ataxia, somnolence, and diplopia (rare at usual therapeutic dosages)
Lamotrigine (Lamictal)
A few controlled studies document its efficacy. The adverse event to prevent is a skin rash, sometimes severe and life threatening, mostly if titration is too rapid.
Adult
25 mg PO qd initially, increase q2wk by 25 mg bid; increase until efficacy or adverse effects, up to 250 mg PO bid
Pediatric
Not established
Acetaminophen increases renal clearance of medication, decreasing effects; similarly, phenobarbital and phenytoin increase lamotrigine metabolism causing a decrease in lamotrigine levels; administration of valproic acid with lamotrigine increases half-life
Documented hypersensitivity
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Monitor for rash and inform patient; other adverse effects are headache, anorexia, nausea, vomiting, and dizziness (infrequent)
Gabapentin (Neurontin)
Same mechanism of action is supposed to play a role here. This drug is more expensive than the other drugs but has a very low adverse effect profile. No controlled study has been completed, but several open trials have reported an improvement on this drug. As for other indications, the adequate dosage seems to vary greatly, and a trial should include raising the dose (eg, 3600 mg/d) as long as no efficacy is yet encountered, before stopping it. It is given in 4 divided doses a day.
Adult
1200-3600 mg/d PO tid/qid
300 mg PO qd initially, then titrate 300 mg/d
Pediatric
Not established
None reported
Documented hypersensitivity
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Caution in impaired renal or hepatic function
GABA-agonists
GABA-agonist effect reduces the central projection of painful afferent impulses.
Baclofen (Lioresal)
Not as often efficient as carbamazepine. Has been demonstrated to be useful by well-conducted clinical studies.
Adult
10 mg PO tid, up to 30 mg PO tid, depending on response and tolerance
5 mg PO bid initially, gradually increase by 5 mg q2-3d
Pediatric
Not established
Opiate analgesics, benzodiazepines, alcohol, tricyclic antidepressants, guanabenz, MAOIs, clindamycin, and hypertensive agents may increase baclofen effects
Documented hypersensitivity
Pregnancy
D - Unsafe in pregnancy
Precautions
Caution in patients with history of autonomic dysreflexia and when spasticity is used to obtain increased function; autonomic dysreflexia can result from withdrawal of this medication
Tricyclic antidepressants
A complex group of drugs that have central and peripheral anticholinergic effects, as well as sedative effects. They have central effects on pain transmission. They block the active re-uptake of norepinephrine and serotonin.
Amitriptyline (Elavil)
A minority of patients might respond to this drug. The anticholinergic adverse effects will be the limitation.
Adult
25-75 mg/d PO qhs
Pediatric
Not established
Phenobarbital may decrease effects; coadministration with CYP2D6 enzyme system inhibitors (eg, cimetidine, quinidine) may increase amitriptyline levels; inhibits hypotensive effects of guanethidine; may interact with thyroid medications, alcohol, CNS depressants, barbiturates, and disulfiram
Documented hypersensitivity; patient has taken MAOIs in past 14 d; has history of seizures, cardiac arrhythmias, glaucoma, and urinary retention
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Caution in cardiac conduction disturbances, history of hyperthyroidism, and renal or hepatic impairment; avoid using in elderly patients
Toxin
Appears to potentially decrease painful afferents, but mechanism of action remains unclear.
Botulinum toxin (BOTOX®)
Subcutaneous injections have been beneficial in a pilot study, but these results await confirmation.
Adult
100 U in the zygomatic arch
Pediatric
Not established
Myasthenia; documented hypersensitivity
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Excessive dosages can cause dysphagia or diplopia
More on Trigeminal Neuralgia |
| Overview: Trigeminal Neuralgia |
| Differential Diagnoses & Workup: Trigeminal Neuralgia |
 Treatment & Medication: Trigeminal Neuralgia |
| Follow-up: Trigeminal Neuralgia |
| Multimedia: Trigeminal Neuralgia |
| References |
| « Previous Page | Next Page » |
References
Al-Din AS, Mir R, Davey R, et al. Trigeminal cephalgias and facial pain syndromes associated with autonomic dysfunction. Cephalalgia. Aug 2005;25(8):605-11. [Medline].
Baker KA, Taylor JW, Lilly GE. Treatment of trigeminal neuralgia: use of baclofen in combination with carbamazepine. Clin Pharm. Jan-Feb 1985;4(1):93-6. [Medline].
Blom S. Trigeminal neuralgia: Its treatment with a new anticonvulsant drug. Lancet. 1962;1:839-40.
Brabant S, Van Zundert J, Van Buyten JP. Pulsed radiofrequency treatment of the gasserian ganglion in patients with essential trigeminus neuralgia: A retrospective study. Proceedings of the World Pain Congress;. 2000;San Francisco, CA.
Browne L. Radiofrequency lesioning of the trigeminal ganglion for the treatment of trigeminal neuralgia. Ir Med J. Mar 1985;78(3):68-71. [Medline].
Cruccu G, Biasiotta A, Galeotti F, et al. Diagnostic accuracy of trigeminal reflex testing in trigeminal neuralgia. Neurology. Jan 10 2006;66(1):139-41. [Medline].
Dalessio DJ. Diagnosis and treatment of cranial neuralgias. Med Clin North Am. May 1991;75(3):605-15. [Medline].
Deinsberger R, Tidstrand J. Linac radiosurgery as a tool in neurosurgery. Neurosurg Rev. Apr 2005;28(2):79-88; discussion 89-90, 91. [Medline].
Dubner R, Sharav Y, Gracely RH, Price DD. Idiopathic trigeminal neuralgia: sensory features and pain mechanisms. Pain. Oct 1987;31(1):23-33. [Medline].
Eide PK, Rabben T. Trigeminal neuropathic pain: pathophysiological mechanisms examined by quantitative assessment of abnormal pain and sensory perception. Neurosurgery. Nov 1998;43(5):1103-10. [Medline].
Evans RW, Graff-Radford SB, Bassiur JP. Pretrigeminal neuralgia. Headache. Mar 2005;45(3):242-4. [Medline].
Fromm GH. Pathophysiology of trigeminal neuralgia. In: Fromm G, Sessle B, eds. Trigeminal Neuralgia: Current Concepts Regarding Pathogenesis and Treatment. Woburn, MA: Butterworth;1991:105-22.
Fromm GH, Terrence CF, Chattha AS. Baclofen in the treatment of trigeminal neuralgia: double-blind study and long-term follow-up. Ann Neurol. Mar 1984;15(3):240-4. [Medline].
Headache Classification Subcommittee of the International Headache Society. The International Classification of Headache Disorders: 2nd edition. Cephalalgia. 2004;24 Suppl 1:9-160. [Medline].
Hess B, Oberndorfer S, Urbanits S, et al. Trigeminal neuralgia in two patients with glioblastoma. Headache. Oct 2005;45(9):1267-70. [Medline].
Khan OA. Gabapentin relieves trigeminal neuralgia in multiple sclerosis patients. Neurology. Aug 1998;51(2):611-4. [Medline].
[Best Evidence] Khedr EM, Kotb H, Kamel NF, et al. Longlasting antalgic effects of daily sessions of repetitive transcranial magnetic stimulation in central and peripheral neuropathic pain. J Neurol Neurosurg Psychiatry. Jun 2005;76(6):833-8. [Medline].
Kondziolka D, Perez B, Flickinger JC, et al. Gamma knife radiosurgery for trigeminal neuralgia: results and expectations. Arch Neurol. Dec 1998;55(12):1524-9. [Medline].
Kondziolka D. Functional radiosurgery. Neurosurgery. Jan 1999;44(1):12-20; discussion 20-2. [Medline].
Olson S, Atkinson L, Weidmann M. Microvascular decompression for trigeminal neuralgia: recurrences and complications. J Clin Neurosci. Sep 2005;12(7):787-9. [Medline].
Pollock BE, Ecker RD. A prospective cost-effectiveness study of trigeminal neuralgia surgery. Clin J Pain. Jul-Aug 2005;21(4):317-22. [Medline].
Rose FC. Trigeminal neuralgia. Arch Neurol. Sep 1999;56(9):1163-4. [Medline].
Tanaka T, Morimoto Y, Shiiba S, et al. Utility of magnetic resonance cisternography using three-dimensional fast asymmetric spin-echo sequences with multiplanar reconstruction: the evaluation of sites of neurovascular compression of the trigeminal nerve. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. Aug 2005;100(2):215-25. [Medline].
Truini A, Galeotti F, Cruccu G. New insight into trigeminal neuralgia. J Headache Pain. Sep 2005;6(4):237-9. [Medline].
Turk U, Ilhan S, Alp R, et al. Botulinum toxin and intractable trigeminal neuralgia. Clin Neuropharmacol. Jul-Aug 2005;28(4):161-2. [Medline].
Vincent M. SUNCT, lacrimation, and trigeminal neuralgia. Cephalalgia. Mar 1998;18(2):71. [Medline].
Further Reading
Keywords
tic douloureux
