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Treatments and drugs
By Mayo Clinic staffTrigeminal neuralgia treatment usually starts with medications, and many people require no additional treatment. However, over time, some people with the disorder eventually stop responding to medications, or they experience unpleasant side effects. For those people, injections or surgery provide other trigeminal neuralgia treatments options.
Medications
Medications to lessen or block the pain signals sent to your brain are the most common initial treatment for trigeminal neuralgia.
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Anticonvulsants. Carbamazepine (Tegretol, Carbatrol) is the drug most commonly prescribed — and with the most demonstrated effectiveness — for trigeminal neuralgia. Other anticonvulsant drugs used to treat trigeminal neuralgia include oxcarbazepine (Trileptal), lamotrigine (Lamictal), phenytoin (Dilantin, Phenytek) and gabapentin (Neurontin).
If the anticonvulsant you're using begins to lose effectiveness, your doctor may increase the dose or switch to another type. Side effects of anticonvulsants may include dizziness, confusion, drowsiness, double vision and nausea. Also, carbamazepine can trigger a serious drug reaction in some people, mainly those of Asian descent, so genetic testing may be recommended before you start carbamazepine.
- Antispasmodic agents. Muscle-relaxing agents such as baclofen may be used alone or in combination with carbamazepine or phenytoin. Side effects may include confusion, nausea and drowsiness.
Alcohol injection
Alcohol injections provide temporary pain relief by numbing the affected areas of your face. Your doctor will inject alcohol into the part of your face corresponding to the trigeminal nerve branch causing pain. The pain relief isn't permanent, so you may need repeated injections or a different procedure in the future. Side effects may include infections at the injection site, bleeding and damage to nearby nerves.
Surgery
The goal of surgery for trigeminal neuralgia is either to stop the blood vessel from compressing the trigeminal nerve or to damage the trigeminal nerve to keep it from malfunctioning. Damaging the nerve often causes temporary or permanent facial numbness, and with any of the surgical procedures, the pain can return months or years later.
Surgical options for trigeminal neuralgia include:
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Gamma-knife radiosurgery (GKR). This procedure involves delivering a focused, high dose of radiation to the root of the trigeminal nerve. Because of GKR's effectiveness and safety compared with other surgical options for trigeminal neuralgia, the procedure is becoming widely used and may be offered earlier than other surgical procedures.
Gamma-knife radiosurgery uses radiation to damage the trigeminal nerve and reduce or eliminate pain. Relief occurs gradually and can take several weeks to begin. GKR is successful in eliminating pain for the majority of people. If pain recurs, the procedure can be repeated. Fewer than 5 percent of people who undergo this procedure experience side effects, which may include lasting loss of facial sensation. The procedure is painless and typically is done without anesthesia.
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Microvascular decompression (MVD). This procedure involves relocating or removing blood vessels that are in contact with the trigeminal root.
During MVD, your doctor makes an incision behind the ear on the side of your pain. Then, through a small hole in your skull, part of your brain is lifted to expose the trigeminal nerve. Any artery in contact with the nerve root is directed away from the nerve, and the surgeon places a pad between the nerve and the artery. If a vein is compressing the nerve, the surgeon typically will remove it.
MVD can successfully eliminate or reduce pain most of the time, but pain can recur in some people. While MVD has a high success rate, it also carries risks. There are small chances of decreased hearing, facial weakness, facial numbness, double vision, and even a stroke or death. Most people who have this procedure have no facial numbness afterward.
Note that if no artery or vein appears to be compressing the nerve, your surgeon may sever part of the nerve, instead. This procedure is called a rhizotomy.
- Glycerol injection. During this procedure, your doctor inserts a needle through your face and into an opening in the base of your skull. The needle is guided into the trigeminal cistern, a small sac of spinal fluid that surrounds the trigeminal nerve ganglion — where the trigeminal nerve divides into three branches — and part of its root. Images are made to confirm that the needle is in the proper location, and then a small amount of sterile glycerol is injected. After three or four hours, the glycerol damages the trigeminal nerve and blocks pain signals. Initially, this procedure relieves pain in most people. However, some people have a later recurrence of pain, and many experience facial numbness or tingling.
- Balloon compression. In balloon compression of the trigeminal nerve, your doctor inserts a hollow needle through your face and into an opening in the base of your skull. Then, a thin, flexible tube (catheter) with a balloon on the end is threaded through the needle. The balloon is inflated with enough pressure to damage the nerve and block pain signals. Balloon compression successfully controls pain in most people, at least for a while. Most people undergoing this procedure experience some facial numbness, and some experience temporary or permanent weakness of the muscles used to chew.
- Electric current (radiofrequency thermal rhizotomy). This procedure selectively destroys nerve fibers associated with pain. While you're sedated, your doctor places a hollow needle through your face and into an opening in your skull. Once the needle is positioned, an electrode is threaded through it to the nerve root. You're then awakened from sedation so that you can indicate when and where you feel tingling from the mild current pulsed through the tip of the electrode. When the neurosurgeon locates the part of the nerve involved in your pain, you are returned to sedation. Then the electrode is heated until it damages the nerve fibers, creating an area of injury (lesion). If your pain isn't eliminated, your doctor may create additional lesions. Almost everyone who undergoes radiofrequency thermal rhizotomy has some facial numbness after the procedure.
- Severing the nerve (rhizotomy). A procedure called partial trigeminal rhizotomy involves cutting part of the trigeminal nerve at the base of your brain. Through an incision behind your ear, your doctor makes a quarter-sized hole in your skull to access the nerve. Because it cuts the nerve at its source, your face will be numb permanently.
- Trigeminal neuralgia fact sheet. National Institute of Neurological Disorders and Stroke. http://www.ninds.nih.gov/disorders/trigeminal_neuralgia/detail_trigeminal_neuralgia.htm. Accessed Feb. 18, 2010.
- Bajwa ZH. Trigeminal neuralgia. http://www.uptodate.com/home/index.html. Accessed Feb. 18, 2010.
- Sohur US. Trigeminal neuralgia. In: Ferri FF. Ferri's Clinical Advisor 2010. St. Louis, Mo.: Mosby; 2009. http://www.mdconsult.com/das/book/body/183930156-4/0/2088/674.html#4-u1.0-B978-0-323-05609-0..00029-0--sc0175_13740. Accessed Feb. 18, 2010.
- Krafft RM. Trigeminal neuralgia. American Family Physician. 2008;77:1291.
- AAN and EFNS guideline on diagnosing and treating trigeminal neuralgia. St. Paul, Minn.: American Academy of Neurology (AAN). http://www.aafp.org/afp/2009/0601/p1001.html. Accessed Feb. 18, 2010.
- Young RF. Trigeminal neuralgia. In: Rakel RE, et al. Conn's Current Therapy 2008. 60th ed. Philadelphia, Pa.: Saunders Elsevier; 2008. http://www.mdconsult.com/book/player/book.do?method=display&type=bookPage&decorator=header&eid=4-u1.0-B978-1-4160-6642-2..00014-4--sc0075&uniq=183930156&isbn=978-1-4160-6642-2&sid=954069268#lpState=open&lpTab=contentsTab&content=4-u1.0-B978-1-4160-6642-2..00014-4--sc0075%3Bfrom%3Dtoc%3Btype%3DbookPage%3Bisbn%3D978-1-4160-6642-2. Accessed Feb. 18, 2010.
- Nerve blocks. Radiological Society of North America. http://www.radiologyinfo.org/en/info.cfm?pg=nerveblock#part_nine. Accessed Feb. 18, 2010.
- Singla A. Trigeminal neuralgia. In: Frontera WR, et al. Essentials of Physical Medicine and Rehabilitation. 2nd ed. Philadelphia, Pa.: Saunders Elsevier; 2008. http://www.mdconsult.com/das/book/body/184337872-8/955217002/1678/94.html#4-u1.0-B978-1-4160-4007-1..50092-4--cesec12_1483. Accessed Feb. 18, 2010.
- Swanson JW (expert opinion). Mayo Clinic, Rochester, Minn. March 1, 2010.
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