What are treatment options for trigeminal neuralgia?

What types of treatment are effective at stopping trigeminal neuralgia?

After being diagnosed with trigeminal neuralgia, you most likely will be referred to a neurologist for care where you are likely to be started on medication to control the condition. Various types of medications, including muscle relaxants, anticonvulsants, and tricyclic antidepressants are effective at stopping the pain for most patients.

While medications work for the majority of patients, they don’t work for every one. Or you may find the side effects of the medication intolerable. Over time, the medication may become less effective.

If medication doesn’t work for any of those reasons, you will be referred to a neurosurgeon to consider surgical options. You should make sure that the neurosurgeon you are seeing specializes in treating patients with trigeminal neuralgia.

If you are referred for surgical treatment, there are three primary types of procedures that should be considered. Be sure your neurosurgeon performs all three so that the pros and cons of each can be considered for you. The surgical procedures most often used to treat TN are:

1. Stereotactic Radiosurgery: This procedure uses high-intensity radiation to create a lesion on the trigeminal nerve root to stop it from sending pain signals to the brain. Neurosurgery One uses the latest SRS technology, called Zap-X Gyroscopic SRS, which does not require you to wear a headframe.
2. Percutaneous Procedures: This procedure is performed by inserting a tiny needle through your cheek and injecting glycerol or a balloon to destroy part of the nerve so it can no longer send pain signals. Another form of the procedure uses radiofrequency energy to burn the nerve.
3. Microvascular Decompression (MVD): This surgical procedure involves moving the blood vessel that is compressing the trigeminal nerve so that it no longer sends pain signals.

These surgical procedures are described in more detail below.

How is stereotactic radiosurgery used to treat trigeminal neuralgia?

Stereotactic radiosurgery, sometimes referred to as gamma knife radiation, uses focused beams of intense radiation to damage the trigeminal nerve. By damaging the nerve, this non-invasive outpatient treatment stops the nerve from conducting pain signals. Since the beams are focused directly on the trigeminal nerve, the procedure results in minimal damage to healthy tissue. The procedure is completed in one visit with essentially no recovery time. Neurosurgery One uses the latest technology, called Zap-X Gyroscopic SRS, to perform stereotactic radiosurgery. This technology does not require patients to wear a head frame.

• Outcomes: Up to 96% chance of improvement (Can be repeated, with secondary procedures providing an 89% success rate, even in those whose condition recurred or who failed initial treatment.)
• Benefits: Outpatient, noninvasive procedure; no anesthesia; virtually no risk or recovery time, other than a 2% chance of permanent numbness (not weakness or sagging)
• Drawbacks: Delayed pain relief, up to a month or more, but typically within one week; slightly lower success rate than other surgical therapies
• Ideal Candidate: Most patients with trigeminal neuralgia; in particular, those with relatively good but not great control who are willing to undergo a very low-impact procedure without any recovery time to lessen their pain, their side effects or their need for medication

Stereotactic radiosurgery can be performed in one day, with patients able to return to work immediately.

What is percutaneous rhizotomy and how is it used to treat trigeminal neuralgia?

Percutaneous stereotactic radiofrequency rhizotomy (PSR) also is used to damage the trigeminal nerve to prevent it from transmitting pain signals. Guided by X-ray, the surgeon inserts a thin needle through the patient’s cheek into the trigeminal nerve to damage it and stop it from transmitting pain signals to the “short circuit” and on to the brain. The surgeon can damage the nerve by injecting glycerol, burning it with radiofrequency energy, or crushing it with a balloon.

With PSR, control rates are slightly higher and recurrence rates are slightly lower than with the other needle-based procedures. Although the incidence of numbness is greatest with this procedure, surgeons use this needle method most often to treat trigeminal neuralgia because, on average, it has the most positive effects with the fewest drawbacks. Percutaneous rhizotomy has a 90-95% rate of curing trigeminal neuralgia, with a low (20-25%) rate of the condition returning, according to a study published in the Journal of Neurosurgery. 

Other points about this procedure:

• Outcomes: 90-95% cure rate, 20-25% recurrence rate
• Benefits: Outpatient procedure; local anesthesia; immediate relief
• Drawbacks: Guaranteed facial numbness, with a 1% chance of severe facial numbness or burning pain called “anesthesia dolorosa”
• Ideal Candidate: Patients who have failed other methods; older patients with anesthesia risks who have such severe pain that they are not eating or drinking adequately

What is microvascular decompression and what are the benefits of using it to treat trigeminal neuralgia?

Available since the 1950s, microvascular decompression (MVD) is also sometimes referred to as posterior fossa exploration. Considered the “gold standard” in trigeminal neuralgia treatment in the past, MVD is still thought by some to be the only good surgical option for trigeminal neuralgia patients. It involves making a small incision behind the ear and implanting a small felt pad between the blood vessels and the trigeminal nerve to alleviate the pressure and resulting “short circuit.”

• Outcomes: Microvascular decompression offers up to a 90–95% cure with 20–25% recurrence.
• Benefits: Immediate relief; less than a 1% chance of serious complications (in the hands of a surgeon with significant experience); minimal risk of numbness
• Drawbacks: Inpatient surgery requiring general anesthesia, small surgical risks and a two-day stay in the hospital, with around two weeks of recovery at home
• Ideal Candidate: Many patients of all ages with limited anesthesia risk; MVD for TN is a safe procedure even in the elderly; the risk of serious morbidity or mortality is similar to that in younger patients

Can multiple types of surgery be performed to treat trigeminal neuralgia, especially if it returns?

In cases of trigeminal neuralgia that don’t respond to treatment, multiple surgical treatments—which can be attempted in any order—can be used and even may be necessary to get long-lasting pain relief.

Although scarring from stereotactic radiosurgery was once believed to prevent the use of other surgical techniques, it has since been found this is not the case. MVD is occasionally repeated, especially after long periods of relief. Occasionally, partial cutting of the nerve (partial sensory rhizotomy, or PSR) is necessary when multiple other attempts have failed.