ABSTRACT
Introduction The medical management and surgical procedures outlined in the preceding chapters are mainly used to treat typical (idiopathic, classic, type 1) trigeminal neuralgia, atypical (type 2) trigeminal neuralgia, or trigeminal neuralgia related to multiple sclerosis. Patients with persistent or recurrent facial pain despite the usual medical and surgical interventions outlined above may represent refractory cases of trigeminal neuralgia or other forms of facial pain or trigeminal neuropathy. It is critical to recognize non-trigeminal neuralgia facial pain, as these patients are less likely to respond to the surgical regimens outlined in the previous chapters, yet are susceptible to the side effects of these procedures, further complicating the patient’s condition. For example, cases of secondary trigeminal neuralgia, due to structural lesions such as tumor or vascular malformation, are best treated by directly addressing the underlying pathology. In the case of true refractory trigeminal neuralgia that has not been alleviated by many of the treatments discussed, this chapter outlines the management strategies and surgical procedures that are available only after the other procedures have been tried or are contraindicated. On this note, it is extremely important that when a patient has tried multiple modalities and still experiences pain from trigeminal neuralgia, a careful medical history is taken. Many additional clinical pearls exist in fully determining a timeline of treatment, which include exact medication dates, dosages, surgeries, side effects, and benefits. For example, Ms Smith may say that lamotrigine did not work in the past at 400 mg in two divided doses. Taken alone, this statement may make many clinicians avoid a second trial. On piecing together a history it is found that she was also on 1800 mg of oxcarbazepine in three divided doses at the same time. With intimate knowledge of the medications one may notice that since
oxcarbazepine is an enzyme-inducing antiepileptic drug (AED), the correct dosage of lamotrigine would be 600 mg when used in conjunction. Now that she no longer is taking an enzyme-inducing AED a second trial of lamotrigine is warranted. A thorough history-taking as discussed in the first chapter again becomes an excellent starting point when determining what else to offer patients with refractory trigeminal neuralgia in terms of therapeutic options. This chapter discusses the additional therapies available.
