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What is the treatment of classical Trigeminal Neuralgia
The most effective medication for Trigeminal Neuralgia is carbamazepine (200 to 2400 mg daily depending upon efficacy and tolerability), with efficacy in 58% to 100% of patients depending upon the study while oxcarbazepine (titrated up to 1800 mg daily depending upon effect and tolerability) is probably as effective as carbamazepine and may be effective in patients not responsive to carbamazepine.
Baclofen (40 to 80 mg daily in three doses slowly titrated up) and lamotrigine (up to 400 mg daily slowly titrated up) are possibly effective while there are limited data on the benefit of other medications including clonazepam, phenytoin, tizanidine, topiramate, pregabalin, misoprostol, and valproate.
Those who fail carbamazepine monotherapy may benefit from combination therapy with baclofen, gabapentin, tizanidine, lamotrigine, or topiramate. One trial found benefit from onabotulinumtoxinA. Acupuncture may be helpful.
Perhaps 40% of patients with TN do not respond to medication treatment.
A joint society position paper of the American Academy of Neurology and the European Federation of Neurological Societies concluded that microvascular decompression, percutaneous procedures on the gasserian ganglion (rhizotomy), and gamma knife are possibly effective.
Sources
Maarbjerg S, Gozalov A, Olesen J, Bendtsen L: Trigeminal neuralgia – a prospective systematic study of clinical characteristics in 158 patients. Headache 54(10):1574-1582, 2014.
