Pharmacological Management

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Carbamazepine remains the drug of choice for the treatment of classical (primary) trigeminal neuralgia (TN). Once the titration period is over, longer-acting formulations or related, safer, medications such as oxcarbazepine may be used. Neutropenia and hyponatremia are possible side effects of carbamazepine. During its use, appropriate blood testing is necessary. If the control of symptoms is incomplete, addition of another drug or switching drugs should be considered.

Oxcarbazepine, a prodrug of carbamazepine, as noted, has a better side effect profile than carbamazepine. Gabapentin has also been shown to be effective in the treatment of TN, particularly in patients with multiple sclerosis.

Some evidence exists to support the use of medications such as lamotrigine or baclofen in the treatment of TN. OnabotulinumtoxinA has also been used successfully for the control of symptoms in TN (see Table 17.6).

Table 17.7 Surgical approaches to treat trigeminal neuralgia

• Microvascular decompression (Jannetta procedure)

• Percutaneous approaches to trigeminal gangliolysis

• Radiofrequency thermorhizotomy

• Balloon microcompression

• Retrogasserian glycerol rhizotomy

• Stereotactic radiosurgery

• Electrical stimulation/neuromodulation

Table 17.8 Pearls on trigeminal neuralgia

• The older the patient, the less likely the TN is secondary

• The younger the patient, the more likely the TN is multiple sclerosis

• TN is terribly painful. If the medicines are maximized and the patient is still symptomatic, refer to the surgeon or pain anesthesiologist quickly

• The older the patient, the better the response to microvascular decompression, but the greater the operative risk

• The older the patient, the greater the risk of anesthesia dolorosa with trigeminal neurolysis

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