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Published online before print August 20, 2008, doi:10.1212/01.wnl.0000326598.83183.04)
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 Volume 71, Number 15, October 7, 2008
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NEUROLOGY 2008;71:1183-1190
© 2008 American Academy of Neurology
Special Articles

Practice Parameter: The diagnostic evaluation and treatment of trigeminal neuralgia (an evidence-based review)

Report of the Quality Standards Subcommittee of the American Academy of Neurology and the European Federation of Neurological Societies

G. Gronseth, MD, FAAN, G. Cruccu, MD, J. Alksne, MD, C. Argoff, MD, M. Brainin, MD, FESO, K. Burchiel, MD, T. Nurmikko, MD, PhD and J. M. Zakrzewska, MD, FDSRCS, FFDRCSI

From the Department of Neurology (G.G.), University of Kansas, Kansas City; Department of Neurological Sciences (G.C.), La Sapienza University, Rome, Italy; Division of Neurosurgery (J.A.), School of Medicine, University of California, San Diego; Albany Medical College and Albany Medical Center (C.A.), Albany, NY; Clinical Neurosciences (M.B.), Department of Clinical Medicine and Prevention, Donau-Universität Krems, Krems, Austria; Department of Neurological Surgery (K.B.), Oregon Health & Science University, Portland; Pain Research Institute (T.N.), Division of Neurological Science, School of Clinical Sciences, University of Liverpool, UK; and University College London Hospital Eastman Dental Hospital (J.M.Z.), UK.

Address correspondence and reprint requests to American Academy of Neurology, 1080 Montreal Avenue, St. Paul, MN 55116 guidelines{at}aan.com

Background: Trigeminal neuralgia (TN) is a common cause of facial pain.

Purpose: To answer the following questions: 1) In patients with TN, how often does routine neuroimaging (CT, MRI) identify a cause? 2) Which features identify patients at increased risk for symptomatic TN (STN; i.e., a structural cause such as a tumor)? 3) Does high-resolution MRI accurately identify patients with neurovascular compression? 4) Which drugs effectively treat classic and symptomatic trigeminal neuralgia? 5) When should surgery be offered? 6) Which surgical technique gives the longest pain-free period with the fewest complications and good quality of life?

Methods: Systematic review of the literature by a panel of experts.

Conclusions: In patients with trigeminal neuralgia (TN), routine head imaging identifies structural causes in up to 15% of patients and may be considered useful (Level C). Trigeminal sensory deficits, bilateral involvement of the trigeminal nerve, and abnormal trigeminal reflexes are associated with an increased risk of symptomatic TN (STN) and should be considered useful in distinguishing STN from classic trigeminal neuralgia (Level B). There is insufficient evidence to support or refute the usefulness of MRI to identify neurovascular compression of the trigeminal nerve (Level U). Carbamazepine (Level A) or oxcarbazepine (Level B) should be offered for pain control while baclofen and lamotrigine (Level C) may be considered useful. For patients with TN refractory to medical therapy, Gasserian ganglion percutaneous techniques, gamma knife, and microvascular decompression may be considered (Level C). The role of surgery vs pharmacotherapy in the management of TN in patients with MS remains uncertain.

Abbreviations: AAN = American Academy of Neurology; CBZ = carbamazepine; CTN = classic TN; EFNS = European Federation of Neurological Societies; MS = multiple sclerosis; NNH = number needed to harm; NNT = number needed to treat; OXC = oxcarbazepine; RCT = randomized controlled trial; RFT = radiofrequency thermocoagulation; STN = symptomatic TN; TN = trigeminal neuralgia.

Supplemental data at www.neurology.org

e-Pub ahead of print on August 20, 2008, at www.neurology.org.

Published simultaneously in the European Journal of Neurology.

Quality Standards Subcommittee members, AAN classification of evidence, Classification of recommendations, Conflict of Interest Statement, and Mission Statement of the Quality Standards Subcommittee (appendices e-1 through e-5), as well as tables e-1 through e-9 and references e1 through e38, are available as supplemental data on the Neurology® Web site at www.neurology.org.

Approved by the Quality Standards Subcommittee February 8, 2008; by the Practice Committee March 20, 2008; and by the AAN Board of Directors June 30, 2008.

Disclosure: Author disclosures are provided at the end of the article.

Received April 2, 2008. Accepted in final form June 26, 2008.






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