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Neurology online by Dr. Strizhak

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Trigeminal Neuralgia Treatment

Trigeminal Neuralgia Treatment – Medications – Microvascular Decompression – Rhuzotomy – Gamma Knife

Drug Treatment of Trigeminal Neuralgia

All medications for trigeminal neuralgia pain control were originally anti-epileptic drugs. This is understandable, because the processes in the nerve cell network in trigeminal neuralgia and epilepsy are similar.

Tegretol, Carbatrol (Carbamazepine)

Tegretol is the most effective drug. Pain relief is dramatic initially but it tends to wane over time. Some patients poorly tolerate the drug. Initial effective dose may be relatively low compared to the antiepileptic. Years down the road, the dose usually has to increased. Some patients increase the dose on their own during the disease exacerbations and end up being intoxicated. Addition of another medication does not appear to be helpful and produces only a placebo effect.
Blood cell count has to be monitored regularly, especially initially. Serious autoimmune reactions reported, especially in people with specific genetic makeup, HLA-B1402 allele, common in Asia.

Trileptal (Oxcarbazepine)

Trileptal is better tolerated and offers comparable, but still inferior to Carbamazepine, pain relief. Side effects are similar to Tegretol but less common.
The most typical issue is hyponatremia (low blood sodium level). General symptoms of dizziness, drowsiness and nausea occur less often.

Lamictal (Lamotrigine)

Lamictal is less effective than the top two medications. It is so much better tolerated that it worth a trial. I have patients who are doing pretty well on Lamictal alone but I always question myself if the remission is natural of the medication related.
Blood metabolic profile and cell count have to be monitored, especially at the start of therapy. Severe skin reactions (such as Stevens-Johnson syndrome) are reported but more typically in children and in combination with Valproate. Lamictal dose has to be increased gradually.

Neurontin (Gabapentin)

Neurontin is only marginally helpful. It may offer some benefit in combination with other agents. All medications have potential side effects, but this one is relatively safe for the body compared to others.

Baclofen

It is an option. Too sedating in high doses.
Basically, any other anticonvulsant can be tried, but the response will be modest at best.

Microvascular Decompression – Rhizotomy – Gamma Knife

Multiple procedures have been developed for patients who do not respond to drug therapy. The type of treatment depends on the cause. Microvascular decompression surgery is an option for proven cases of a vascular loop. All others are offered one or the other type of rhizotomy.

Microvascular Decompression Surgery

This procedure is intended to protect a trigeminal nerve root from pulsating vascular loop by placing a Teflon pad between the nerve and the artery loop. It is an open brain surgery under a general anesthesia.
This procedure is intended to protect, rather than damage, the nerve. All other interventions are meant for exactly the opposite – they all damage the trigeminal nerve or its ganglion to some extent.

Rhizotomy (“nerve root injury”)

Rhizotomy literally means “cutting nerve root”. Physical cutting of the trigeminal nerve for pain relief was introduced a long time ago. It is not employed for trigeminal neuralgia pain control any longer. All procedures described below are meant to induce some level of damage to the trigeminal nerve and have similar side effect profiles. The individual procedure effectiveness depends on severity of the nerve injury induced, so does the chance of the complications.
In my opinion, it does not matter much how the nerve is damaged. One of my patients has severe, poorly controlled trigeminal neuralgia. She was, eventually, referred for Gamma Knife Rhizotomy. She never got there. Diagnosed with cancer, she underwent chemotherapy. Surprisingly, her trigeminal neuralgia became significantly better after chemotherapy. She still had to take Tegretol, but this time it was working. Years down the road, her pain is still well controlled with medications. My guess is that the improvement was due to chemotherapy induced trigeminal neuropathy.

Stereotactic Radiosurgery(Gamma Knife)

Trigeminal nerve root entry zone is stereotactically radiated. The effect of the treatment and the side effects depend of the radiation dose. There are no universally accepted protocols for this procedure and the data is still being accumulated. Higher dose translates into better pain control and higher chance of side effects.
Long term complications for this procedure are not known yet. There a few studies reporting a decent response to the treatment. Based on my personal professional experience, I would assign a 50/50 chance of improvement. Interestingly, this type of rhizotomy may produce pain relief only months later.

Glycerol Rhizotomy

Nerve fibers are not like copper wires. They don’t exist on their own. The fibers carrying signals from receptors to the trigeminal nerve nucleus belong to special neurons. The bodies of these neurons are sitting in Gasserian ganglion within trigeminal nerve. Absolutely all the information about sensation is passing through this ganglion.
Glycerol is injected in the area surrounding Gasserian ganglion. Trigeminal pain relief might be modest or temporary (compared to other procedures see below). The advantage is that the complication rate is low and glycerol rhizotomy may be repeated multiple times, if needed. It is the gentlest procedure of all described on this page.

Balloon Compression Rhizotomy

Gasserian ganglion is briefly physically compressed with a small balloon, which is inserted through a thick needle and inflated. The balloon, together with the needle, is removed after a few minutes. The effectiveness and the side effect profile are comparable with Glycerol injection.

Radiofrequency Rhizotomy

A special electrode is inserted into Gasserian Ganglion. In this procedure, the nerve is injured by the heat. Even though, it is the most effective for pain control, the rate of permanent sensory loss on the face is the highest of all modern types of rhizotomy.

The most common complications are decreased sensation in the eye, weakness in chewing muscles, chronic unpleasant sensation in the face and anesthesia dolorosa. (see below)

Anesthesia Dolorosa

Anesthesia dolorosa is a potential complication of any rhizotomy. It is a combination of a lost sensation in the face and severe, burning aching pain in the same area.
Medications are absolutely ineffective. Multiple surgical procedures were attempted with mixed results.

Conclusion:

Trigeminal neuralgia is a chronic debilitating pain syndrome. Most of the patients can be successfully managed with medications. Surgical and minimally invasive procedures are available for those who have a poor response to conservative treatment.

Any comments about this page will be greatly appreciated at doctorstrizhak@gmail.com Content copyright 2017. DOCTORSTRIZHAK.COM. All rights reserved.
Disclosure: This Web Site is intended for education purpose only. The information provided on this site must not be perceived as a guide for self-diagnosis or self-treatment. Every effort is made to keep the information current, but there are absolutely no guarantees of timely updates. By Andre Strizhak