eMedicine Specialties > Ophthalmology > Neurologic Disorders
Trigeminal Neuralgia: Treatment & Medication
Updated: Jan 29, 2010
- 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 cases are resistant to any type of treatment.
Carbamazepine and oxcarbazepine are considered first-line therapy. Lamotrigine and baclofen are second-line therapy. Other treatments are third line and the evidence for their efficacy is scant.
Treatment for trigeminal neuralgia must be tailored individually, based on the patient's age and general condition. In the case of symptomatic trigeminal neuralgia, adequate treatment is that of its cause, the details of which are out of the scope of this article. Use of pharmacoprophylaxis or of surgical techniques used for the classic form can be tried, but no scientific evidence of efficacy has been produced.
- Carbamazepine (Tegretol, Carbatrol) was introduced in the 1960s and has proven its efficacy in numerous studies. It remains the criterion standard of treatment for trigeminal neuralgia.8,9
- Oxcarbazepine (Trileptal) has not been studied as extensively, but efficacy outcomes are similar. Better tolerability can be considered an advantage over carbamazepine.10
- 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).11
- Baclofen has demonstrated its efficacy but with a lower degree of evidence.12,13
- Gabapentin (Neurontin) seems to be effective, but no controlled studies are available.14
- Phenytoin (Dilantin) is not recommended. Only anecdotal evidence exists. The dose varies greatly among patients.
- Clonazepam (Klonopin) has moderate efficacy but is not recommended because of a low level of evidence and its adverse effects (eg, sedation) and dependence.
- Amitriptyline (Elavil) can be tried, but the success rate is low.
Surgical Care
The timing for surgery is debatable, and no randomized study has addressed this question. However, the earlier a surgical technique is applied, it seems the better the outcome. At least 2 medication trials should be performed and carefully evaluated before more invasive techniques are instituted.15
The success rate varies according to the experience of the surgeon or the anesthesiologist, and, therefore, surgical correction should be performed only by experienced surgeons. Surgical therapy can be divided into procedures on the nerve or gasserian ganglion (external or percutaneous, usually performed by pain management specialists) and on the nerve root (open skull surgery called microvascular decompression and performed by neurosurgeons, and gamma-knife radiation performed by radiation therapists). Microvascular decompression has an overall better success rate, but it is more invasive. Percutaneous techniques may be more accessible to elderly patients who are at high surgical risk.
- On the nerve root
- Jannetta pioneered microvascular decompression. 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 greater than 80%. Recurrence rates are among the lowest (20% at 1 y, 25% at 5 y) compared with other invasive treatments.16,17 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. Complications include chemical meningitis, ipsilateral hearing loss, and facial sensory loss or palsy. Mortality rates in experienced centers are less than 0.5%.A surgical image is below.
Microvascular decompression (Jannetta procedure) used to treat trigeminal neuralgia. The anteroinferior cerebellar artery and the trigeminal nerve are in direct contact. Courtesy of PT Dang, CH Luxembourg.
- Gamma-knife treatment consists of multiple rays (>200) of high-energy photons concentrated with high accuracy on the target (ie, trigeminal nerve root).18,19 This treatment destroys specific components of the nerve. Of those treated, 60% of patients are immediately free of pain, and more than 75% of patients have greater than 50% relief after 1.5 years. Recurrence rates are around 25 % between 1 and 3 years. This treatment can be used after a patient does not 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 the clinical image below.
MRI with high resolution on the pons demonstrating the trigeminal nerve root. In this case, the patient with trigeminal neuralgia has undergone gamma-knife therapy, and the left-sided treated nerve (arrow) is enhanced by gadolinium.
- On the gasserian ganglion
- 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.
- Pulsed radiofrequency on the trigeminal ganglion appears promising in reports.20,21 Likewise, linear-accelerated particle radiation appears to be a valid alternative.
- On the peripheral nerve
- Percutaneous radiofrequency rhizotomy and percutaneous microcompression with balloon inflation are relatively inexpensive and accessible techniques, and they are 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.
- Alcohol or phenol injection of the trigeminus can be performed at various locations along the nerve, and the goal is to destroy 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. Recurrence rates are around 50 % at 1 year.
- Clinical guideline summaries
- International RadioSurgery Association -Stereotactic radiosurgery for patients with intractable typical trigeminal neuralgia who have failed medical management22
- American Academy of Neurology and the European Federation of Neurological Societies -Practice parameter: The diagnostic evaluation and treatment of trigeminal neuralgia (an evidence-based review)23
Consultations
Pain management specialists and/or a neurosurgeon should be consulted depending on the modality used to correct the trigeminal neuralgia.
Diet
No specific diet is recommended in trigeminal neuralgia.
Activity
Other than avoiding the triggers of trigeminal neuralgia, the activity of the patient should remain normal.
Medication
Treatment of trigeminal neuralgia is prophylactic. Indeed, no abortive therapy has been 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.12 Duration of treatment depends on clinical evolution but usually is long-term, often lasting years. Topical analgesics have failed.24
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; 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 - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Most frequent adverse effects are dizziness, ataxia, diplopia, hyponatremia, vertigo, and sedation. Life-threatening rashes can occur (rare and dose dependent); bone marrow suppression is rare but necessitates monitoring; monitor CBC count (bone marrow suppression) and sodium (hyponatremia) level 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 toxicity; effects may decrease when taken concurrently with barbiturates, diazoxide, ethanol (chronic ingestion), rifampin, antacids, charcoal, carbamazepine, theophylline, or sucralfate; 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 - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
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 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, not to exceed 250 mg PO bid
Pediatric
Not established
Acetaminophen increases renal clearance of lamotrigine, decreasing effects; similarly, phenobarbital and phenytoin increase lamotrigine metabolism, causing a decrease in lamotrigine levels; administration of valproic acid increases half-life
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
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. 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, 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. 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 - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in impaired renal or hepatic function
Oxcarbazepine (Trileptal)
Close cousin of carbamazepine; presumably works on similar mechanisms. Offers a better tolerance and is easier to manage. Studies are limited, as opposed to the large body of high-level evidence with carbamazepine.
Adult
Average routine dose ranges 600-1800 mg/d; titration can be over a couple of weeks
Pediatric
Not established
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Most frequent adverse effects are dizziness, ataxia, diplopia, hyponatremia, vertigo, and sedation; life-threatening rashes can occur (rare and dose dependent); bone marrow suppression is rare but can be monitored with CBC count (bone marrow suppression); monitoring of sodium (hyponatremia) levels not necessary; monitor blood levels for toxicity or suspected noncompliance but not as routine
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, TCAs, guanabenz, MAOIs, clindamycin, and hypertensive agents may increase effects
Documented hypersensitivity
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
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. Anticholinergic adverse effects are 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 levels; inhibits hypotensive effects of guanethidine; may interact with thyroid medications, alcohol, CNS depressants, barbiturates, and disulfiram
Documented hypersensitivity; MAOIs in past 14 d; history of seizures, cardiac arrhythmias, glaucoma, or urinary retention
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in cardiac conduction disturbances, history of hyperthyroidism, and renal or hepatic impairment; avoid using in elderly patients
Toxin
Recent experimental approach, mentioned to respond to patient inquiries. Not recommended because of scant evidence of efficacy. Appears to potentially decrease painful afferents, but mechanism of action remains unclear.25
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 - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
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 |
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Further Reading
Keywords
trigeminal neuralgia, trigeminal nerve, headache, neuralgia, paroxysmal headache pain, tic douloureux, neuropathic pain, microvascular decompression, Jannetta procedure
