Trigeminal Neuralgia Treatments and Medications

Anyone who has lived through a root canal knows there are few experiences more excruciating than facial pain. People with trigeminal neuralgia—damage to the nerve that communicates facial sensations to the brain—live with the constant threat of brief, stabbing facial pain that can strike anytime. Fortunately, healthcare professionals have an arsenal of medications and surgical techniques that can reduce or eliminate pain for many patients, making a normal life possible.

What is trigeminal neuralgia?

Trigeminal neuralgia (TN) is a nerve condition characterized by recurrent bouts of sudden, stabbing, and brief facial pain. Minor sensations such as cold, wind, eating, touching the face, or talking can trigger these pain attacks. They can recur regularly for several weeks and then be followed by weeks, months, or years with no pain whatsoever.

Also called tic douloureux, trigeminal neuralgia results from the squeezing of the trigeminal nerve near its root in the skull. The trigeminal nerve (or cranial nerve V) emerges from the skull as a single nerve, but branches out into three major nerves that provide sensation and movement to the forehead, eyes, upper jaw, nose, and lower jaw. The pressure on the nerve root damages the protective myelin sheath around the nerve as well as outer nerve fibers. Vibrations or contact trigger irritation where the nerve is damaged, and the irritation generates misfired impulses, radiating pain to parts of the face.

In most cases—80% to 90%—the nerve damage is caused by a blood vessel compressing the trigeminal nerve as it exits the skull. Called classic or idiopathic trigeminal neuralgia, the condition is primarily treated by antiepileptic drugs or surgery. Sometimes, however, an underlying condition such as a tumor, cyst, or multiple sclerosis is the culprit, a condition called symptomatic or atypical trigeminal neuralgia. Treatment will focus on the underlying problem.

How is trigeminal neuralgia diagnosed?

Trigeminal neuralgia is usually diagnosed based on the patient’s symptoms. Most patients bring the problem to a general practitioner or emergency room physician, but the final diagnosis and treatment will be made by a neurologist.

The characteristic symptom of trigeminal neuralgia is mild to severe stabbing facial pain that is:

• Sudden and shock-like

• Brief (lasting seconds to minutes)

• Usually occurring on one side of the face

• Comes and goes

• Is often triggered by minor facial sensations such as touching the cheek, vibrations, cold, wind, brushing teeth, eating, or talking

Aside from a medical history, the doctor will perform a physical examination of the head and neck, as well as a neurological examination. Generally, the neurologic examination is normal in a patient with classical trigeminal neuralgia, but upon physical exam it would assist in verifying a diagnosis if specific trigger zones were identified. Some reflex tests, such as loss of corneal reflex in the eye (blinking) or weakness in any of the facial muscles might point toward a diagnosis of symptomatic trigeminal neuralgia.

If a patient history reveals the pain is moderate but never goes away, a more serious condition such as multiple sclerosis or tumor may be the cause. Magnetic resonance imaging (MRI) using contrast dye will be used to scan the head as part of any diagnostic work-up. The purpose of the MRI is to exclude secondary causes from a diagnosis of classic trigeminal neuralgia, or in preparation for surgery in the management of classic trigeminal neuralgia.

Trigeminal neuralgia treatment options

Trigeminal neuralgia is initially treated with medications. If medical therapy doesn’t work, surgical options are available to provide relief from flare-ups.

Medications

Antiepileptic drugs (AEDs), also called anticonvulsants, are the first-line therapy for trigeminal neuralgia. These drugs work by interfering with the transmission of overactive pain signals, but they also have serious side effects. A neurologist may also prescribe baclofen, a muscle relaxant, to reduce the anticonvulsant dose. If one drug doesn’t work, neurologists will try other antiepileptic drugs, antidepressants, or anesthetics. Many of these therapies are unproven, but they may work for some patients.

Surgery

Medical treatment of trigeminal neuralgia may fail for several reasons: the drugs may not work, their effectiveness may wear off after time, or the side effects may be too hard to live with. As many as half of trigeminal neuralgia patients eventually undergo some form of surgery. Many will experience significant pain relief for anywhere from one to several years. Surgical treatments aim to either relieve the pressure on the nerve or to selectively damage nerve fibers that communicate pain signals.

• Microvascular decompression (MVD) provides the most sustained pain relief but is the most invasive neurosurgical procedure for trigeminal neuralgia. A neurosurgeon moves the blood vessel that is squeezing the trigeminal nerve, essentially fixing the cause of the problem. The procedure is performed under general anesthesia, requires a hospital stay, and does come with risks of serious complications. However, the success rate is high.

• Percutaneous rhizotomy is often used in patients with trigeminal neuralgia who may not be good candidates for the more invasive microvascular decompression procedure due to age or other conditions. In these procedures, the trigeminal nerve is partly injured just where it emerges from the skull. The surgeon inserts a device or hollow needle through the skin and uses heat (radiofrequency lesioning), chemicals (glycerol injections), or mechanical means (balloon compression) to destroy pain fibers while preserving other nerve fibers.

• Gamma Knife radiosurgery (GKRS) is not technically surgery. Nothing is actually cut. The Gamma Knife device precisely aims a high dose of high-energy radiation right where the trigeminal nerve exits the skull. After treatment, nerve cells slowly die off over the next several months. As they die off, the pain signals get “scrambled” and stop making it to the brain. Therefore, the pain relief from this procedure is not immediate, but the procedure is done on an outpatient basis and provides several years of pain relief in four out of five patients. With this procedure, there is a risk that nerve connections may regrow.

Trigeminal neuralgia medications

There are only three “proven” drugs used to treat trigeminal neuralgia: carbamazepine, oxcarbazepine, and baclofen. They do not work for everyone, and many patients may not be able to endure the side effects. If that happens, a neurologist may prescribe other drugs that have worked in some patients. Except for carbamazepine, all are prescribed off-label, and doses can vary greatly from patient to patient.

Anticonvulsants

The only drug solidly proven to provide pain relief for trigeminal neuralgia is carbamazepine, an anti-epileptic drug (AED) normally prescribed to patients who have seizures. Also called anticonvulsants, drugs like carbamazepine prevent seizures by blocking repetitive excitatory electrical signals that travel down the length of nerves. Carbamazepine, however, can produce serious side effects and may gradually lose effectiveness over time. A neurologist may then prescribe a similar anticonvulsant called oxcarbazepine. Other anticonvulsants, such as lamotrigine, topiramate, or valproic acid, may also be tried if first-line therapy doesn’t work.

For trigeminal neuralgia, gabapentin, and pregabalin, drugs commonly prescribed for nerve pain, are often the second-line therapy of choice. They can provide effective pain relief with fewer side effects than other anticonvulsants. As a last resort, a neurologist may prescribe clonazepam, an anticonvulsant that works much the same way as gabapentin. It can control trigeminal nerve pain in some patients but has serious side effects, including sedation and dependence.

The problem with anticonvulsants is that they have to be swallowed, but some patients may be in too much pain to swallow a pill. In those cases, a neurologist or emergency room physician may use intravenous anticonvulsants such as phenytoin, fosphenytoin, or levetiracetam to provide immediate pain relief.

Baclofen

Baclofen is a skeletal muscle relaxant that is primarily used to treat moderate to severe back pain. However, it doesn’t relieve trigeminal neuralgia as a muscle relaxant. Instead, baclofen reduces a chemical, called Substance P, in the central nervous system that’s essential to transmitting pain signals. Baclofen is a proven therapy for trigeminal neuralgia, but other muscle relaxants are not. It is often prescribed to enhance the effects of carbamazepine to allow for lower doses and fewer side effects.

Botulinum toxin injection

Botulinum toxin A, better known as Botox, paralyzesnerves. A small amount is injected near the roots of the upper jaw and lower jaw branches of the trigeminal nerve. The goal is to neutralize the pain fibers while preserving the other nerve fibers. Studies have shown that most people with trigeminal neuralgia experience significant pain relief for weeks or months after a botulinum toxin injection, so some neurologists will use it as an alternative to surgery.

Other medications

Aside from carbamazepine, oxcarbazepine, and baclofen, the American Academy of Neurology (AAN) considers all other trigeminal treatments as “unproven.” To avoid surgery, neurologists may try additional classes of drugs, including antidepressants (sumatriptan or amitriptyline) and anesthetics (capsaicin).

What is the best medication for trigeminal neuralgia?

While only a few drugs are proven effective for trigeminal neuralgia, neurologists rely on a number of drugs because not all medications work for everyone. Patients may need to try several different medications, so there is no “best” medication for trigeminal neuralgia.

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Best medications for trigeminal neuralgia