All trigeminal neuralgia patients should undergo medical therapy initially as many patients respond very well to medications.  Anti-seizure medications work well in treating trigeminal neuralgia.  The best medication for trigeminal neuralgia is Tegretol (Carbamazepine) which relieves trigeminal neuralgia in about 60% of patients initially.  Other trigeminal neuralgia medications include, either as a single agent or in combination, Dilantin, Neurontin, Baclofen and Keppra.  Success rates for these medications are in the range of 30-40%.

For many patients, toxicity (e.g. bone marrow and liver toxicity for Tegretol) and side-effects (drowsiness, dizziness, imbalance for all trigeminal neuralgia medications) are not insignificant, and when taking Tegretol, blood tests are required on a regular basis to monitor the liver and bone marrow functions as well as the blood drug level.

Medical therapy must be closely monitored to achieve the goal of pain relief while minimizing side-effects.  At times, when treating trigeminal neuralgia that is refractory to a single agent, a second (or third) medication may be added to adequately control trigeminal neuralgia as long as there is not a significant extent of side-effects.

Epidemiology (“How common is it, and how is its distribution?”)

1. The incidence of trigeminal neuralgia (“How common is it?”) is about 40/million population/year.
2. Trigeminal neuralgia is more common in the female sex (F:M 1.7:1).
3. Over 80% of trigeminal neuralgia patients are older than 50 years of age at the                           time of onset.
4. 5-8% of trigeminal neuralgia patients have a brain mass (i.e. brain tumor or cyst) causing direct compression on the trigeminal nerve.
5. 2-9% of trigeminal neuralgia patients have multiple sclerosis (MS).
6. 2-4% of MS patients have trigeminal neuralgia.

Natural History

1. 25% of patients experience spontaneous resolution after the initial episode(s), and experience trigeminal neuralgia recurrence months to years later.
2. Approximately 50% of trigeminal neuralgia patients initially managed medically will eventually require surgical intervention due to:
   1. Failed medical therapy
      1. Ineffective medical therapy
      2. Significant side-effects
   2. Personal choice

Etiology (“What causes trigeminal neuralgia?”)

For patients other than those with MS or brain lesions found to be causing trigeminal neuralgia, the “vascular compression theory” is the popular one explaining the cause of trigeminal neuralgia in the majority of patients.  Aging leads to mild brain sagging as well as blood vessel elongation, hardening and dilatation, all of which lead to the nearby blood vessel(s) coming into direct contact with the trigeminal nerve.  This “vascular compression” on the trigeminal nerve leads to certain changes (“demyelination”) within the nerve, ultimately resulting in “short-circuiting” among nerve fibers, which in turn causes the trigeminal neuralgia’s typical electrical shock-like pain.