First line of treatment for patients with trigeminal neuralgia TGN should always be medical, usually the anticonvulsant carbamazepine (Tegretol®), which provides at least partial pain relief for 80% to 90% of patients. Common side effects include dizziness, drowsiness, forgetfulness, unsteady gait, and nausea. However, carbamazepine and other drugs prescribed do not always remain effective over time, requiring higher and higher doses or a greater number of medications taken concurrently, causing many patients to experience side effects serious enough to warrant discontinuation.
A study from the 1980s followed 143 TGN patients treated with carbamazepine (CBZ) over a 16-year period. The drug was effective initially with few mild side effects in 99 patients (69%). Of these, 19 developed resistance between 2 months and 10 years after commencing treatment, and required alternative measures. Of the remaining 80 (56%), the drug was effective in 49 for 1-4 years and in 31 for 5-16 years. Thirty-six patients (25%) failed to respond to CBZ initially and required alternative measures, as did 8 (6%) who were intolerant of the drug.
Surgical treatment of TGN is reserved for people who still experience debilitating pain despite best medical management. Surgical options include gamma knife “radiosurgery” (GKS) and the more invasive microvascular decompresion (MVD).
Another study from 2008 compared outcomes for 80 consecutive TGN patients treated surgically with either MVD (36 patients) or GKS (44 patients) over 4-8 years:
In sum, MVD was more likely than GKS to achieve and maintain pain-free status in TGN,but both procedures provided similar early patient satisfaction rates. MVD is therefore preferred for younger healthy patients, while GKS is preferred for older patients with co-morbidies or contraindications, but neither should be considered unless medical therapy has already been tried and failed.