The first treatment for trigeminal neuralgia usually is carbamazepine (Tegretol and others). Carbamazepine is an anticonvulsant medication that decreases the ability of the trigeminal nerve to fire off the nerve impulses that cause facial pain. If carbamazepine is not effective, other possible drug choices include phenytoin (Dilantin), gabapentin (Neurontin), lamotrigine (Lamictal), topiramate (Topamax), and valproic acid (Depakene, Depakote). A muscle relaxant such as baclofen (Lioresal) can be tried alone or in combination with an anticonvulsant. Narcotic pain relievers, such as oxycodone, hydrocodone or morphine (several brand names), may be taken briefly for severe episodes of pain.
Some of these medications carry the risk of unpleasant side effects, including drowsiness, liver problems, blood disorders, nausea and dizziness. For this reason, people taking any of these medications may be monitored with frequent follow-up visits and periodic blood tests. After a few pain-free months, your doctor may attempt to decrease the dose of the medication gradually or discontinue it. This is done to limit the risk of side effects and to determine whether your trigeminal neuralgia has gone away on its own.
If medication does not stop your pain or if you cannot tolerate the side effects of medication, then your doctor may suggest one of the following treatment options:
Rhizolysis – In this approach, part of the trigeminal nerve is inactivated temporarily by using one of the following methods: a heated probe, an injection of the chemical glycerol or a tiny balloon that is inflated near the nerve to compress it. During the procedure a needle or a tiny hollow tube called a trocar is inserted through the skin of your cheek. These procedures provide immediate relief in up to 99% of patients, but 25% to 50% of people will have the problem return during the next several years.
Stereotactic radiosurgery – This form of radiation therapy uses a linear accelerator or a gamma knife to inactivate part of the trigeminal nerve. After your head is positioned carefully in a special head frame, many tiny beams of radiation are aimed precisely at the part of the trigeminal nerve that must be inactivated. Stereotactic radiosurgery is a fairly new treatment option for trigeminal neuralgia, and its long-term success rate is still being evaluated.
Microvascular decompression of the trigeminal nerve – In this delicate surgical procedure, a surgeon carefully repositions the blood vessel that is pressing on your trigeminal nerve near your brain. Because this procedure involves opening your skull, the ideal candidate for this procedure is someone who is generally healthy and younger than 65. Overall, the immediate success rate is approximately 90%, and 70% to 80% of patients have long-term relief. Microvascular decompression may be effective for patients who have not had success with one of the less invasive surgeries.