Therapeutic approaches in trigeminal neuralgia – a comprehensive review

Background and objectives. Trigeminal neuralgia (TN) is a debilitating neuropathic disorder characterized by sudden, severe facial pain triggered by light stimuli. While first-line pharmacotherapy provides relief for many patients, a significant proportion experience drug intolerance or treatment resistance. This review synthesizes recent evidence to offer clinicians a consolidated view of established and emerging therapies for TN. In contrast to prior reviews, it emphasizes updated data on botulinum toxin, comparative long-term outcomes of surgical options, and the role of minimally invasive procedures in modern treatment algorithms. Materials and methods. We conducted a narrative review of 44 peer-reviewed articles published in Web of Science between 2010 and 2024. Web of Science was selected to ensure inclusion of rigorously peer-reviewed, high-impact studies across diverse regions and specialties. Eligible studies included randomized controlled trials, meta-analyses, large cohort series, and consensus guidelines focused on pharmacological, interventional, and surgical treatments for TN. Studies addressing other facial pain syndromes without direct relevance to TN were excluded. Results. Carbamazepine and oxcarbazepine remain first-line treatments, with initial response rates of 70–90%. Baclofen, gabapentinoids, and lamotrigine offer additional benefit in selected cases. Botulinum toxin type A has emerged as a minimally invasive option for drug-refractory TN, showing consistent pain reduction in small trials and meta-analyses. Microvascular decompression provides the highest long-term pain relief for classical TN, while stereotactic radiosurgery and percutaneous ablative procedures offer effective alternatives for patients unfit for open surgery. Sensory complications and recurrence rates vary across interventions. Conclusions. TN management should follow a structured therapeutic pathway: first-line pharmacological agents (carbamazepine or oxcarbazepine), followed by adjunctive medications or botulinum toxin for refractory cases, and escalation to surgical interventions – microvascular decompression when neurovascular conflict is confirmed, or stereotactic radiosurgery/percutaneous ablation in patients with significant comorbidities. Future research should focus on predictive markers of treatment response and long-term comparative outcomes.