Trigeminal neuralgia

Opinion statement

• The initial treatment for trigeminal neuralgia is medical. Carbamazepine is the drug of choice.

• If the patient proves to be intolerant of carbamazepine, a number of second-line drugs are available, though data on their relative efficacy are nonexistent. Phenytoin, baclofen, clonazepam, and sodium valproate are all worthy of consideration. Oxcarbazepine may be as effective as carbamazepine, but its availability is limited.

• Newer agents being tried in this condition include lamotrigine and gabapentin. Their comparative value has not been established.

• For patients resistant to or intolerant of drug therapy, interventional or surgical procedures are necessary. For younger, fit patients, particularly with involvement of the first division or all three divisions of the nerve, microvascular decompression is recommended.

• For older patients, for those not shown to have microvascular cross-compression, and for those not willing to undergo craniectomy, radiofrequency thermal rhizotomy is probably the next treatment of choice. Dogmatic recommendations are not appropriate in the absence of truly comparable data. Other techniques to be considered, if thermal rhizotomy is unsuccessful, include glycerol rhizotomy, balloon compression, partial sensory trigeminal rhizotomy, and peripheral neurectomy. The choice is given in no particular order. Patients offered such treatments require data on the track record of the relevant institution in performing that procedure.

• Stereotactic radiosurgery is still being evaluated for this condition. Because the associated morbidity is very low, it may become the treatment of choice for the elderly frail patient if longer-term follow-up establishes its continuing benefit.