MEDICATION

Many patients find that TN can be effectively managed with medication. Even though the pain of TN may come and go, it is necessary for a TN patient to take medication regularly to prevent the sudden onset of an attack. Taking medication sporadically is ineffective, and abrupt withdrawal of medications can cause side effects.

Once a patient has been pain free for four to six weeks, the medication may be gradually tapered off but only on your doctor’s advice.

Analgesics (such as aspirin and Nurofen) and narcotics are ineffective against TN because attacks are usually sudden and long term use of narcotics is not advisable.
Anticonvulsant medications which slow down the nerve’s conduction of pain signals are usually the first treatment option for classical TN.

Carbamazepine (Tegretol) has been the primary drug used to treat TN. Many neurologists believe that the relief of facial pain with Tegretol confirms the diagnosis of TN. The drug is introduced slowly and increased by the doctor to a level where the patient is pain free or side effects occur. It has been shown in controlled clinical trials to be effective in approximately 60% of patients with TN.

Oxcarbazepine (Trileptal) extended-release anticonvulsant tablets are used in combination with other medications. It works by decreasing abnormal electrical activity in the brain. It is a derivative of carbamazepine which came to the market in 2000.

Phenytoin (Dilantin) is another drug that is used to treat TN, especially if the patient has had adverse side effects to Tegretol. Since Dilantin may also be administered intravenously, it is sometimes used to stop an acute attack, such as in the emergency room. Dilantin is considered to be less effective in addressing TN, but it may be better tolerated by the elderly patient.

These drugs, which are also used as anticonvulsants, generally are thought to work by blocking the firing mechanism of the nerve. The more common side effects are dizziness, drowsiness, forgetfulness, unsteadiness and nausea. Serious side effects may occur although they are rare. They include anemia, liver toxicity and kidney dysfunction. Patients on Tegretol and Dilantin should have periodic blood counts to monitor any blood abnormalities.

Gabapentin (Neurontin) is a more recent anticonvulsant. Since it is eliminated by the body rather than metabolized it is felt to be more easily tolerated and to cause less liver toxicity. Neurontin has also been found to be beneficial in the treatment of some atypical facial pain syndromes and other painful nerve problems.

Baclofen (Lioresal) is a muscle relaxant that may be used alone or in combination with other medications. It seems to help increase their effectiveness if additional medication is needed.

Other medications used in the treatment of TN may include clonazepan (Rivotril) and sodium valporate (Epilim).

During all phases of medical treatment, patients need to communicate their pain level and / or drug side effects to their neurologist or other health care professional so that medication can be regulated effectively. These medications work best with a consistent blood level, so they must be taken on a regular schedule.

To avoid serious side effects, including seizures, anticonvulsant dosages must be increased and decreased slowly as directed by your doctor. Do not stop these medications abruptly. The drugs tend to work on an all or nothing principle. They do not give partial relief as the dosage is increased; they work when the correct dosage is reached, so dosage must be individualized with each patient.

Anticonvulsants can be given in combinations. Neurontin and Baclofen are often given as a second drug along with one of the other anticonvulsants.

Alcohol and other sedatives should be avoided with most of these drugs.

Switching medications may be necessary, so in order to maintain a pain relieving blood level of medication, discuss with your doctor how to begin the new medication while tapering off of the old one.

Long term use of anticonvulsant drugs have been found to deplete bone mass, leading to osteoporosis, so bone density testing and calcium supplements are recommended.

About 80% of TN patients will respond to medications and find their TN symptoms can be effectively managed with drugs; however, 20% will not. Consult your neurologist for complete information regarding medication dosages and specific questions about them.

SURGICAL OPTIONS

A sizable number of TN patients achieve long term relief from medication. Those for whom medication does not provide relief or those who suffer unacceptable side effects from medication, may want to consider surgery.

There are several surgical interventions used to treat TN, none of which is 100% effective in all cases. Collectively, these procedures have an initial response rate of about 80%, with approximately 25% of patients experiencing some level of recurrence within one to five years. Many of these patients respond very well when surgery is repeated or other medical management is pursued.

The surgical techniques used to treat TN range from procedures performed at day surgery to damage the nerve to that of invasive surgery that requires a hospital stay of several days duration. Determining which procedure is the best choice for a particular person should be based on several factors such as the patients preference, physical well being, previous surgeries, presence of multiple sclerosis, and area of trigeminal nerve involvement particularly where the upper/ophthalmic branch is involved.

Undoubtedly, recommendations by the neurologist or neurosurgeon will play a strong part in the patient’s decision making process. The Support Group is not an advocate for any individual mode of treatment, but serves to provide information on the various treatments available so that patients can explore all their options.

RADIOFREQUENCY RHIZOTOMY

This is one of the most effective and safest procedures for relieving TN pain. During the procedure – which is usually performed on an outpatient basis while the patient is sedated – an electrode designed to destroy the part of the nerve that causes pain is placed on the nerve using a needle inserted through the cheek. A moderate amount of numbness around the area where the pain was located is an expected side effect of this procedure.
Statistics overseas have indicated that after 5 years, 50% of patients were pain free.

GLYCEROL RHIZOTOMY

This procedure is similar to radio frequency rhizotomy. Instead of inserting an electrode into the nerve, the surgeon injects an alcohol substance, called glycerol, which bathes the nerve and damages the pain fibres. As with the radio frequency rhizotomy, minor numbness can be expected following this procedure.
Statistics have indicated that this procedure is less effective than the radio frequency rhizotomy with less than 50% pain free after 4 years.

BALLOON COMPRESSION

This again is a similar procedure but in this case a tiny balloon is inserted through a catheter into the trigeminal ganglion (the central part of the nerve that transmits nerve impulses) and then inflated. The inflated balloon compresses the nerve and damages the pain fibres. Again minor numbness may result.

MICROVASCULAR DECOMPRESSION

This is the most invasive of all surgical options to treat TN, but it also offers the lowest probability that the pain will return within 5 years. This surgery aims to remove the cause of the problem rather than damaging the nerve.
With the patient anesthetized, a small opening is made behind the ear. While viewing the trigeminal nerve through a microscope, the surgeon places a soft cushion (typically shredded Teflon) between the nerve and the blood vessels that are compressing it. In some cases the compressing blood vessels are removed. The procedure usually takes two to four hours and patients can expect a hospital stay of at least two to five days.
Statistics have shown that in excess of 80% were pain free, either with no medication or some medication, after 5 years.

ALTERNATIVE / COMPLIMENTARY TREATMENTS

There are a number of alternative treatments that may assist in alleviating the pain and reducing the need for drugs or surgery. Often sufferers will seek alternative treatments because of lack of effectiveness or side effects of the drugs or due to failed surgery. Some may be suffering from atypical TN pain for which drugs or surgery may provide only limited pain relief.
As an example, several members of the support group have achieved pain relief from:

• Kinesiatric remedial massage treatment
• Chiropractic Therapy
• Acupuncture
• Homeopathic treatments
• Capsaicin and topical compounds especially for post herpetic neuralgia
• Nutritional therapy
• Medical Cannabis
• Electrical Nerve Stimulation
• Transcutaneous Electrical Nerve Stimulation (TENS)
• Upper Cervical Chiropractic (UCC)
• Vitamin B-12 injections
• Vitamin Therapy
• PEA (Palmitoylethanolamide)
• Botox
• Low Intensity Laser Therapy (LILT)
• Herbal Remedies and vitamins
• Special diets such as the low saturated fat diet and neuro stimulation

Medical Marijuana Cannabinoids may prove useful in pain modulation by inhibiting neuronal transmission in pain pathways.

Botox can help to keep the muscle relaxed for anywhere from three to six months. Injection to the maxillary and mandibular roots seems to be a highly effective method. In the event of recurrence, after each injection, the pain severity and attack frequency decreased.