Choosing The Right Trigeminal Neuralgia Treatment by Michael Brisman, M.D., F.A.C.S.

What Is Trigeminal Neuralgia?

Trigeminal neuralgia sufferers experience brief, severe episodes of sharp facial pains, similar to electric shocks or stabbing pains. Patients feel the pain anywhere from the forehead down to the chin, and the pains can be triggered by a light touch.

First Line Trigeminal Neuralgia Treatment: Medications

Trigeminal neuralgia pain relief usually occurs with the use of anti-seizure medications such as Trileptal, or Tegretol. These medications are usually the best trigeminal neuralgia medications, and there are others, including Neurontin and Lyrica. Many patients will benefit from the medicines, and many will also have spontaneous episodes of remission where the pain goes away for weeks, months, or even years. If a patient has persistent pains or side effects, we may consider a procedure.

Microvascular Decompression Surgery

Although microvascular decompression surgery is the most invasive of the procedures, it usually works immediately and has the best chance of being curative. I prefer this procedure for otherwise healthy people under age 65 who do not have multiple sclerosis or hearing loss. This is because there is a slight chance of hearing loss on the side of the head where the procedure is performed. During microvascular decompression surgery, we move the blood vessel away from the nerve.

Less Invasive Procedures: Choosing Rhizotomy or Gamma Knife
When patients have significant medical problems, including MS, we choose one of the less invasive procedures: Rhizotomy or Stereotactic Radiosurgery using a machine called the Gamma Knife. The Rhizotomy is best for patients requiring immediate relief. Most patients feel better right away, whereas some have to wait a few days for the Rhizotomy to become effective. However, the Rhizotomy is more invasive than the Gamma Knife because it requires insertion of a needle into the skull.

Rhizotomy techniques include using heat, RF, alcohol, glycerol, or balloon inflation to injure the nerve. I perform this procedure under IV sedation with local anesthesia.

The Gamma Knife machine uses stereotactic radiation, and there are no needles involved. The Gamma Knife is less invasive, but it can also be less effective. For example, patients may still require medications post-procedure. The treatment also takes longer to work, up to several weeks.

Mild To Moderate Nerve Injury
The Rhizotomy and Gamma Knife procedures injure the nerve. I prefer to use mild to moderate, rather than severe, nerve injury techniques because they carry less risk of complications, such as new numbness or facial pain. Severe nerve injuries can offer longer lasting pain relief, but they carry greater risks.

In summary, there are many different treatment options for trigeminal neuralgia and many different considerations when deciding which treatments are best for a particular patient.