A 63-year-old woman comes in after two weeks of episodic, severe left facial pain. She describes the pain as a sharp lightening-bolt sensation confined to the distribution of the second division of trigeminal nerve. The pain occurs in paroxysms lasting for seconds. Touching her left cheek can trigger the pain. She is obviously in distress, at times crying during the examination. Her neurological examination is normal.
You are convinced the patient has trigeminal neuralgia (TN) and wonder if you should conduct diagnostic tests to look for its cause.
After reading the AAN practice parameter you find that routine MRI “may be considered” in such patients. The recommendation has a “Level C” rating because it is based on studies that may have overestimated the prevalence of symptomatic cases of TN. In your experience as a general neurologist, patients with these typical manifestations only rarely prove to have a sinister cause and you reasonably judge that MRI is unnecessary in this patient.
You start therapy with carbamazepine (Tegretol). This helps but the patient has difficulty tolerating the medication because of diplopia and vertigo. You switch the drug to oxcarbazepine (Trileptal).
She tolerates this medication well but the pain is only partially controlled. Despite using a maximally tolerated dose, she continues to have bouts of severe pain, especially while eating. She is losing weight and is desperate for immediate relief.
You consider switching her to another medication or adding a second medication, but according to the AAN practice parameter, the evidence does not strongly support using any other medication. The strength of the evidence is similar to that supporting the effectiveness of various surgical interventions. Additionally, some forms of surgery are effective immediately.
You discuss the treatment options with your patient. She would like to try something that might work immediately. She is also aware that there will be some risk associated with surgery. Risks should be explained explicitly here. You refer her to a neurosurgeon with experience in vascular decompressive surgery for trigeminal neuralgia. She returns three weeks later pain-free and with no complications of surgery.