Trigeminal neuralgia type 1 has a short list of medications that are in some cases just absolutely spectacular and life-changing for the treatment of this condition. One of those is Carbamazepine (its other name is Tegretol) and that medication is so reliably good that for somebody who has this condition and has never been treated with this medication before, it's almost certain that their symptoms will get either markedly better or in most cases go away. The problem is: with time, a tolerance will build to these medicines, so the natural history (or in other words: what happens as the disease progresses) is that the medications become less and less effective, the doses have to be raised and ultimately in many patients, the symptoms again reappear and we either have to add medication or seek other treatment options including surgery or radiation. To be more specific, the common medications for this condition are Tegretol or Carbamazepine. Another medication that's commonly used is Gabapentin or Neurontin. Baclifin is another medication, but if you look at the classes of these medications, they are anti-seizure medications. That's what we are typically using to treat this condition because we feel that the underlying problem here is some sort of short circuiting and anticonvulsant or antiseizure medications help calm or stabilize the signal and therefore symptoms get better with the use of these drugs.
Medication for trigeminal neuralgia type 1 is usually prescribed during the episodes of symptoms. Most patients will take these medications life-long. We usually prefer to give people "drug holidays", which is where the drug will be stopped if their symptoms go away in the hopes that they don't develop a tolerance to the drug. The natural history or the natural progression of this condition, however, is that we find the drugs become less and less effective over time. We need higher and higher doses, which is why many patients after several years of having this condition do ultimately need some sort of intervention, whether it's radiation, a needle procedure, or brain surgery.
Although there are a number of treatments for trigeminal neuralgia (medication, rhizotomy - which is a procedure where we put a needle into the nerve, radiation, and surgery - those are a list of possible treatment options) there's only one treatment that offers an opportunity for a long-term cure and that is surgery. Surgery offers an opportunity to cure this disorder, but it is not a 100% cure rate. So we're looking at cure rates somewhere in that 60-70% range, which may not sound high, but it's remarkably higher than any of the other treatment options which either offer no opportunity for a cure or a much, much lower percentage cure rate.
There are two main categories of surgical interventions that get done for trigeminal neuralgia type 1. The one that people mostly read about or hear about is a procedure called microvascular decompression. That involves a craniotomy and a craniotomy is making an actual opening in the skull. An opening is made in the skull. The surgeon then actually inspects the nerve with the use of a microscope. Typically what's found there is a blood vessel resting on the nerve itself. The neurosurgeon will then place a piece of teflon or some other inert material between the nerve and the blood vessel and the result of that (in most cases) is that the patient then wakes up free of their trigeminal neuralgia pain and in a majority of patients, they are cured of their affliction for years, decades to come. The other category of surgical intervention is where we are actually putting a needle through the cheek, up into the nerve, and then in some fashion making a controlled injury to the nerve. Some surgeons make that controlled injury with heat. Some surgeons use a balloon. Some surgeons use another type of liquid, which will actually injure the nerve in a very controlled way. That's the other kind of intervention that gets done. The advantage of that is that you don't have to have a craniotomy. The disadvantage is that the cure rate is far, far less - perhaps more on the order of 50% treatment rates at 2-3 years, rather than surgery, which offers a 70% treatment or cure rate at 10 years.
Stereotactic radiosurgery used for the treatment of trigeminal neuralgia automatically brings up in most patients a lot of concerns about radiation. "Is it going to make me sick? Am I going to lose my hair? What are the side effects of radiation to my brain or body?" Those are a lot of misconceptions about radiation harking back to decades before. Modern radiation is completely different. Patients don't lose their hair. The amount of radiation seen by the brain or the rest of the body is very, very small - almost negligible. All of the radiation is really controlled and focused with use of very, very expensive and powerful computers to just a small sphere (about four millimeters in size.) A lot of the fears and concerns that people have surrounding radiation really aren't true for this kind of treatment. It's a very, very different treatment than radiation say for cancer or radiation for other types of disorders like tumors.
Stereotactic radiosurgery is another treatment modality that can be used to treat trigeminal neuralgia type 1. In this treatment, what we're doing is we're delivering a very, very high dose of radiation to the trigeminal nerve, but we're delivering all of that radiation to a very, very tiny spot. That gives this controlled injury to the nerve which, again, interrupts the conduction and stops the painful episodes on the patient's face. In fact, the machine that I'm standing in front of is a radiosurgical unit. This is the couch that the patient would sit on and the machine behind me would precisely deliver that radiation just to that area of the nerve. You don't lose your hair during this. The other parts of the brain don't get radiation and all of the radiation is delivered to that nerve - the trigeminal nerve. In most patients, pain relief is felt not immediately, but a few months later and in many patients for years to come.
The stereotactic radiosurgery treatment for trigeminal neuralgia type 1 is a single treatment, so the patient gets the treatment typically in 60 minutes to 90 minutes and that is it. They are done. You can drive into the clinic, get your treatment, drive back home, enjoy dinner and wine if you want. It's not an ongoing treatment, but rather a single treatment.
Trigeminal neuralgia type 1 is characterized by these sharp episodes of pain on the face. One of the treatment options for this is rhizotomy, where we're actually trying to section parts of the nerve in order to prevent those painful episodes from occurring. In this case, a rhizotomy is typically done through a needle. There are a variety of ways which can then be done to actually sever or stop those painful episodes from conducting through the nerve. What's commonly used is a radio-frequency rhizotomy. It's a big technical word for using heat at the tip of the needle to deaden part of the nerve and it stops the electrical impulse from conducting and the patient's face then gets numb and people get better. There are other forms of rhizotomy as well. One is a glycerol rhizotomy where we're actually injecting a special type of liquid to injure the nerve and stop it from conducting the electrical impulse. Yet another type of rhizotomy-like procedure is again done through a needle, except this time instead of heat or a liquid, we're actually blowing up a balloon and applying pressure to the nerve and thereby partially stopping that conduction of the electrical impulse. Fundamentally, in the end, it's a needle being put through the cheek all the way up through the skull base into the nerve, and then (in one fashion or another, as we've just described) stopping that electrical impulse from getting from the face back to the brain. For reasons that aren't 100% clear, the pain stops, part of the face gets numb, and the patient feels much, much better and can usually stop a lot of their medications. It's usually a temporary procedure. In some patients it's permanent, but in most patients the pain will return a few years later.
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