Treatment process for trigeminal neuralgia

Treatment

Drug therapy with carbamazepine is effective 50 to 70% of patients. Carbamazepine should be started as a single dose of 100mg taken with food, and increased gradually ( by 100mg daily every 1 to 2 days) until substantial (>50%) pain relief is achieved.

Most patients required a maintenance dose of 200 mg qid. Doses > 1200mg daily provide no additional benefits. Dizziness, imbalance, sedation, and rare cases of agranulocytosis are the most important side effects of carbamazepine if treatment is effective it is usually continued for approximately 1 month and then tapered as tolerated.

If carbamazepine is not well tolerated or is ineffective, phenytoin, 300 to 400 mg daily , can be tried. Baclofen may also be administered, either alone or in combination with carbamazepine or phenytoin. The initial dose is 5 to 10 mg tid, gradually increasing as needed to 20mg qid.

If drug treatment fails, surgical therapy should be offered. The most widely applied procedure creates a heat lesion of the Trigeminal ganglion or nerve a method termed radio frequency thermal rhizotomy injection of glycerol in Meckel’s cave is a method preferred by some surgeons.

Either procedure produces short-term relief in >95% of patients: however, long-term studies indicates that pain recurs in a substantial % of treated patients.

Complications are infrequent in experienced hands. These procedures result in partial numbness of the face and carry a risk of corneal deneravation, with secondary keratitis when used for first division Trigeminal neuralgia.

A third treatment microvasular decompression requires a sub occipital craniotomy. This procedure has a >70% efficacy rate and a low rate of pain recurrence in responders in a small number of cases, there is preioperative damages to the 8th or 7th nerve.

High-resolution magnetic resonance angiography may be useful preoperatively to visualize the relationship between the 5th cranial nerve root and nearby blood vessels.

Treatment of both idiopathic and secondary Trigeminal neuralgia should begin with medications, proceeding to surgery only when there appears to be related series anatomic lesion or when the pain becomes refractory to medications.

Anticonvulsant medications, such as carbamazepine and Baclofen, are effective in treatment idiopathic trigeminal neuralgia and the secondary Trigeminal neuralgia of multiple sclerosis.

Carbamazepine stabilizes neural membrane by decreasing sodium and potassium conductance, there by suppressing neuronal firing. It is prescribed in an initial dose of 200mg/ day and eventually increased to 800 to 1200-mg/ day in divided doses.

Its use can be associated with idiosyncratic blood dyscrasias, including aplastic anemia and leukopinenia,. Baclofen is an analog of the intrinsic inhibitory neurotransmitter aminobutyric acid (GABA), which appears to decrease presynaptic release of excitatory neurotransmitters.

Management

• Patients with Trigeminal neuralgia are best seen at an early stage by a specialist in order to confirm the diagnosis and initiate treatment

• Medical treatment is used successfully for most patients, typically using anticonvulsants.

• Carbamazepine is still he main anticonvulsant used. It is not an analogesic and if given when and attack starts, will not relive the pain.

It must be given continuously prophylactically for long periods, typically starting with 100m 3 times daily, increasing by 100 mg every 3 days to a maximum of 1000 mg / day , to try to control the pain while at the same time to avoid adverse effects,

• If carbamazepine fails to control the pain , phenytoin, clonazepam or baclofen are occasionally useful

• If medical treatment fails or the adverse drug effects are too pronounced , surgery may be required .

For intractable cases, neurosurgery such as destruction of the Trigeminal ganglion or decompression of the Trigeminal nerve may be required . Unfortunately , pain is exchanged for anesthesia and risk of damage to the cornea, or occasionally, continuous anesthesia but with pain.

 

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