Choosing the right treatments for trigeminal neuralgia depends on the cause of your pain and many other factors. These include medical history, side effects, risks, how quickly treatments relieve the pain and how long pain relief lasts. There can be overlap in treatment options for the three different types of trigeminal neuralgia. But not all options are right for everyone.
Treatment options may include medicines, surgery, injections or other procedures. If trigeminal neuralgia is caused by another medical condition, such as multiple sclerosis, treatment may be needed for the underlying condition.
Medicines
Often, medicines are recommended as the first line of treatment for trigeminal neuralgia. Sometimes, no other treatment is needed. The following kinds of medicines are common choices to lessen or block the pain signals sent to the brain.
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Antiseizure medicines. Most often, carbamazepine (Tegretol, Carbatrol, others) or oxcarbazepine (Trileptal, Oxtellar XR) are prescribed to treat trigeminal neuralgia. These medicines are shown to be effective in stopping or reducing pain. Genetic testing may be recommended before starting carbamazepine. It is known to trigger a serious reaction in some people, mainly those of Asian descent.
If these medicines don't work for you, other choices may include gabapentin (Neurontin, Gralise, Horizant) or pregabalin (Lyrica). Lamotrigine (Lamictal), phenytoin (Dilantin, Phenytek, Cerebyx) or topiramate (Qudexy XR, Topamax, others) may be prescribed as well.
Your care team may increase the dose or switch to another type if these medicines become less effective over time. Side effects of antiseizure medicines may include dizziness, confusion, drowsiness and nausea.
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Muscle relaxants. Muscle-relaxing medicines such as baclofen (Gablofen, Fleqsuvy, others) may be used alone or in combination with carbamazepine. Side effects may include confusion, nausea and drowsiness.
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Botox injections. Small studies have shown that onabotulinumtoxinA (Botox) injections may reduce pain from trigeminal neuralgia in people who are no longer helped by medicines. However, more research needs to be done before this treatment is widely used for this condition.
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Pain relievers. During episodes of pain, lidocaine may be used on its own or with other medicines to offer relief. Results tend to be best when lidocaine is used along with another treatment. Lidocaine is available as an aerosol that can be sprayed into the nose or mouth. Also, it can be injected directly into the area where pain is felt. Or it can be given intravenously (IV). This means it is injected into the bloodstream. Lidocaine treatments often need to be repeated.
Surgery
If medicines don't work, and your pain is caused by a blood vessel pressing on your trigeminal nerve, surgery may be recommended. The surgery for trigeminal neuralgia is called microvascular decompression (MVD). MVD is shown to be most effective for long-term pain relief, although it may come with serious risks.
During MVD, a surgeon moves or removes blood vessels that touch the trigeminal nerve to stop the pain from happening. A cut, known as an incision, is made behind the ear on the side where you feel the pain. Then the surgeon makes a small hole in your skull. This procedure is known as a craniotomy. Through this hole, the surgeon moves any arteries that are in contact with the trigeminal nerve. Finally, a soft cushion is placed between the nerve and the arteries.
If a vein is pressing on the nerve, the surgeon may remove it. Part of the trigeminal nerve may be cut if arteries aren't pressing on the nerve. This is known as a neurectomy.
Microvascular decompression can stop or reduce pain for many years. Long-term pain relief depends on the location of pain, type of pain and age of the person. Only a small number of people may have pain come back 3 to 5 years after surgery.
Risks of MVD include hearing loss, stroke, facial weakness, numbness or other complications. Most people who have this procedure have no facial numbness afterward.