Trigeminal neuralgia: for one nerve a multitude of treatments

Trigeminal neuralgia (TN) is reputed to be one of the most painful conditions in human experience. Thus, many treatments, both medical and surgical, have been developed for this relapsing and remitting, paroxysmal stabbing or electrical, facial pain syndrome. The likely etiology in many cases is vascular compression of the trigeminal nerve root entry zone, leading to focal demyelination and aberrant neural discharges. MRI may disclose neurovascular contact, although not with sufficient sensitivity or specificity to substitute for careful clinical diagnosis. In treating TN, antiepileptic drugs are superior to traditional analgesics. Carbamazepine is the first choice drug. Additional drugs for which there is evidence of efficacy include oxcarbazepine, baclofen, gabapentin, lamotrigine and phenytoin. Many patients eventually experience tachyphylaxis or may not tolerate effective doses. Surgical options include: microvascular decompression; balloon compression; radiofrequency thermocoagulation or glycerol rhizotomies; and subcutaneous alcohol branch blockade. Stereotactic gamma knife radiosurgery is a further option. Motor cortex stimulation and transcranial magnetic stimulation, although having shown initial promise for trigeminal neuropathic pain, seem to be ineffective for classical TN. The choice of drug, whether or when to operate, and which procedure to choose should be individualized to the particular needs and conditions of the patient.