Come trattare la nevralgia del trigemino

TREATMENT OF TRIGEMINAL NEURALGIA

The Guidelines for trigeminal neuralgia were first published in 2008 and the European ones were updated in 2019 and include input from all stakeholders.
There remain relatively few randomised control trials and most treatments are based on expert opinion.
A multidisciplinary approach for the treatment of trigeminal neuralgia is crucial. The  teams should include pain physicians , oral physicians , headache neurologists, psychologists, physiotherapists and clinical nurse specialists.

The treatment of trigeminal neuralgia begins with drugs and it is very important to start with low doses and raise the dose slowly, no faster than every three days.  This reduces the number of side-effects . It is useful for patients to use a pain diary to record pain relief, quality of life and side-effects. Anticonvulsants remain the major drugs. All unfortunately have significant side effects including cognitive impairment .

Treatment begins  with carbamazepine and oxcarbazepine but one needs to be aware of sensitivity especially in Asian patients and drug interactions are common. Second -line drugs include lamotrigine, gabapentin, pregabalin, baclofen and Botox.

Some patients will require polytherapy especially those with multiple sclerosis. Regular monitoring is essential. 

Acute flare up will often require admission as patients need to be re-hydrated. Phenytoin or  fosphenytoin IV can be used as inpatient with cardiac monitoring . Sumatriptan subcutaneously has been reported as being helpful.  Local anaesthetic given into trigger points by dentally qualified staff can be temporarily useful while titrating up oral drugs.

If poor tolerance or lack of efficacy is noted, then neurosurgical approach needs to be considered. it is very important that patients have a consultation with a neurosurgeon and a physician before their  severe episode of pain so they can assess the pros and cons of different procedures.  If  there is neuro vascular compression noted on MRI scans the best option is microvascular decompression . It is a major surgical procedure but is non-destructive . In  correctly diagnosed patients and with an experienced  neurosurgeon, 70 to 80% of patients will be pain-free and off drugs at 10 years.

Other procedures are the so-called ablative or destructive procedures, three of which are done at Gasserian ganglion level : radio-frequency thermocoagulation , glycerol rhizotomy or balloon compression. These all result in unpredictable sensory changes and patients can be pain-free for 2 to 4 years and off medication. The procedures can be repeated but there is a risk of anaesthesia dolorosa. The  procedures are done under short anaesthetic and can be done in patients with significant medical  co morbidities. The least invasive procedure is stereotactic radiosurgery where the nerve is targeted in the route entry zone . This may give longer pain relief than the other procedures, but also carries with it the risk of sensory change and there is a delayed response.

Surprisingly there are new drugs in the pipeline. Vixotrigine , a selective sodium channel blocker , has undergone a phase 2 study  which has shown efficacy and has fewer side-effects than the current drugs.  Basmiglurant a selective glutamate receptor antagonist is currently in phase II/III safety and efficacy trials internationally. There are at least another two drugs being planned for investigations and use in trigeminal neuralgia, one of which is a repurposed drug.

The impact of trigeminal neuralgia on quality of life and mood is significant and, together with cluster headache, has a higher incidence of suicide than any other headache or facial pain.  Patients find it difficult to cope with uncertainty, isolation and fear of recurrence.   A program run by psychologists, physiotherapists and clinical nurse specialists on how to manage trigeminal neuralgia, practice mindfulness and have flare-up plans has been shown to be of great value. Meeting fellow sufferers is of great importance in reducing loneliness, and there are patient support groups in several countries that enable patients to meet fellow sufferers and exchange experiences. 

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