Therapeutic Approach for Trigeminal Neuralgia: A Systematic Review

Trigeminal neuralgia improvement following Transcutaneous Electrical Nerve Stimulation (TENS): a systematic review and meta-analysis

BACKGROUND

Trigeminal neuralgia (TN) is a prevalent and debilitating craniofacial pain disorder characterized by severe, unilateral, shock-like pain. Standard treatments include anti-epileptic drugs and surgical interventions, but many patients experience limited relief or adverse effects. Non-invasive therapies, such as transcutaneous electrical nerve stimulation (TENS), have emerged as alternative options. This systematic review and meta-analysis aimed to evaluate the efficacy of TENS in managing primary trigeminal neuralgia.

METHODS

A comprehensive search of PubMed, Cochrane Library, and Google Scholar was conducted, yielding 89 papers. Following selection criteria, five clinical trials involving 101 patients with primary TN and TENS treatment were included. Data on pain severity, TENS parameters, and outcomes were extracted. Statistical analysis was performed using RevMan software, with outcomes assessed using Visual Analogue Scale (VAS) scores before and after TENS treatment.

RESULTS

Pre-treatment VAS scores averaged 8.75 ± 0.18, indicating severe pain. Post-treatment, the mean VAS score significantly decreased to 1.17 ± 0.55, demonstrating substantial pain relief. The meta-analysis revealed a mean difference of 7.49 (95% CI: 7.05 to 7.93) in VAS scores, with a p-value < 0.05, indicating statistically significant pain reduction. Heterogeneity among studies was moderate (I2 = 57%). Complications were infrequently reported, with one study noting paresthesia in a small number of patients.

CONCLUSION

TENS appears to be an effective and safe intervention for reducing pain in patients with primary trigeminal neuralgia. Despite variability in treatment protocols and follow-up periods, the overall evidence supports TENS as a viable option for managing TN pain. Future research should focus on standardizing TENS protocols and evaluating long-term efficacy and safety.

Nanotechnology in Pain Management

Chronic pain is a debilitating condition that affects millions of patients worldwide, contributing to a high disease burden and millions of dollars in lost wages, missed workdays, and healthcare costs. Opioids, NSAIDs, acetaminophen, gabapentinoids, muscle relaxants, anticonvulsants, and antidepressants are the most used medications for chronic pain and carry significant side effects, including gastric bleeding, hepatotoxicity, stroke, kidney damage, constipation, dizziness, and arrhythmias. Opioids in particular carry the risk of long-term dependence, drug tolerance, and overdose. In 2022, 81,806 people died from opioid overdose in the United States alone. Alternative treatments for chronic pain are critically needed, and nanotechnology has emerged as a promising means of achieving effective long-term analgesia while avoiding the adverse side effects associated with conventional pharmacological agents. Nanotechnology-based treatments include liposomes, Poly Lactic-co-Glycolic Acid (PLGA) and other polymeric nanoparticles, and carbon-based polymers, which can help mitigate those adverse side effects. These nanomaterials can serve as drug delivery systems that facilitate controlled release and drug stability via the encapsulation of free molecules and protein-based drugs, leading to longer-lasting analgesia and minimizing side effects. In this review, we examine the role of nanotechnology in addressing concerns associated with conventional chronic pain treatments and discuss the ongoing efforts to develop novel, nanotechnology-based treatments for chronic pain such as nanocapacitor patches, gene therapy, the use of both viral and non-viral vectors, CRISPR, and scavengers.

Progress in treatment of pathological neuropathic pain after spinal cord injury

Pathological neuropathic pain is a common complication following spinal cord injury. Due to its high incidence, prolonged duration, tenacity, and limited therapeutic efficacy, it has garnered increasing attention from both basic researchers and clinicians. The pathogenesis of neuropathic pain after spinal cord injury is multifaceted, involving factors such as structural and functional alterations of the central nervous system, pain signal transduction, and inflammatory effects, posing significant challenges to clinical management. Currently, drugs commonly employed in treating spinal cord injury induced neuropathic pain include analgesics, anticonvulsants, antidepressants, and antiepileptics. However, a subset of patients often experiences suboptimal therapeutic responses or severe adverse reactions. Therefore, emerging treatments are emphasizing a combination of pharmacological and non-pharmacological approaches to enhance neuropathic pain management. We provide a comprehensive review of past literature, which aims to aim both the mechanisms and clinical interventions for pathological neuropathic pain following spinal cord injury, offering novel insights for basic science research and clinical practice in spinal cord injury treatment.

Trigeminal Neuralgia in the Presence of a Vascular Loop and Response to Medical Management: Experience From Saudi Arabia

INTRODUCTION

Trigeminal neuralgia (TN) is a neurovascular disorder characterized by severe, episodic facial pain, often attributed to vascular compression of the trigeminal nerve. The commonly reported artery responsible for compression is the superior cerebellar artery. Additionally, the anterior inferior cerebellar artery is also noted as a potential contributor to vascular loop compression. These vascular structures can lead to nerve root atrophy or displacement, which is significant in the pathophysiology of TN. While extensively studied globally, the specific characteristics of TN in the Saudi Arabian population remain underexplored. The primary objective of this study is to evaluate the response to medical management in patients with TN and vascular loop compression.

METHODS

The study was conducted at King Fahad Specialist Hospital in Dammam, Saudi Arabia, from April to August 2023, and utilized a retrospective case series design to review medical reports of 13 patients diagnosed with TN and vascular loop compression. The primary objective was to evaluate the response to medical management in this specific patient population.

RESULTS

In this study, we included 13 patients with TN, providing a comprehensive snapshot of the patient population under study, encompassing demographic characteristics, clinical presentations, treatment responses, and other relevant variables. The mean age of the patients in the study is 48.23 years, with a standard deviation of 11.7, and a range from 30 to 71 years. The main findings of this study underscore the positive response to medical management in patients with TN and vascular loop compression. All patients in the study responded positively to the treatment, indicating a favorable overall response rate. The time to respond varied, with the majority responding within three months (46.16%), followed by those responding within 12 months (38.46%).

CONCLUSION

This study highlights the potential efficacy of non-surgical approaches in managing the debilitating facial pain associated with TN. The positive outcomes observed in response to medical management emphasize the need for further exploration and validation of non-surgical approaches in the context of TN with vascular loop compression. This finding contributes to the global understanding of TN and offers promise for improving patient quality of life in Saudi Arabia.

An update on pharmacotherapy for trigeminal neuralgia

INTRODUCTION

Trigeminal neuralgia is a rare condition that can be effectively treated by carbamazepine or oxcarbazepine but these older drugs are associated with dose-dependent and potentially treatment-limiting adverse effects. Third-generation anticonvulsants, new calcitonin gene-related peptide blockers for migraine, and older drugs such as ketamine and cannabinoids may be promising adjuvants or monotherapeutic options.

AREAS COVERED

The new drugs, their presumed mechanisms of action, safety and efficacy are discussed herein. There is a paucity of robust clinical evidence in support of these drugs for trigeminal neuralgia. New migraine agents are considered as well although migraines and trigeminal neuralgia are distinct, albeit similar, conditions. No new drugs have been released to market in recent years with the specific indication of trigeminal neuralgia.

EXPERT OPINION

In real-world clinical practice, about half of trigeminal neuralgia patients take more than one agent for prevention and combination therapy may be the optimal approach. Combination therapy might allow for lower doses of carbamazepine or oxcarbazepine, thus reducing the number and severity of potential adverse events but the potential for pharmacokinetic drug-drug interactions must be considered. Drug therapy for trigeminal neuralgia involves acute or abortive treatments, often administered in hospital versus long-term preventive therapy, usually involving oral agents.

Modern Approaches to the Treatment of Acute Facial Pain

PURPOSE OF REVIEW

Acute facial pain presents a complex challenge in medical practice, requiring a comprehensive and interdisciplinary approach to its management. This narrative review explores the contemporary landscape of treating acute facial pain, delving into pharmacological, non-pharmacological, and advanced interventions. The significance of tailored treatment strategies, rooted in the diverse etiologies of facial pain, such as dental infections, trigeminal neuralgia, temporomandibular joint disorders, sinusitis, or neurological conditions like migraines or cluster headaches, is underscored. We particularly emphasize recent advances in treating trigeminal neuralgia, elucidating current treatment concepts in managing this particular acute facial pain.

RECENT FINDINGS

Recent research sheds light on various treatment modalities for acute facial pain. Pharmacotherapy ranges from traditional NSAIDs and analgesics to anticonvulsants and antidepressants. Non-pharmacological interventions, including physical therapy and psychological approaches, play pivotal roles. Advanced interventions, such as nerve blocks and surgical procedures, are considered in cases of treatment resistance. Moreover, we explore innovative technologies like neuromodulation techniques and personalized medicine, offering promising avenues for optimizing treatment outcomes in acute facial pain management. Modern management of acute facial pain requires a nuanced and patient-centric approach. Tailoring treatment strategies to the individual's underlying condition is paramount. While pharmacotherapy remains a cornerstone, the integration of non-pharmacological interventions is essential for comprehensive care. Advanced interventions should be reserved for cases where conservative measures prove inadequate. Furthermore, leveraging innovative technologies and personalized medicine holds promise for enhancing treatment efficacy. Ultimately, a holistic approach that considers the diverse needs of patients is crucial for effectively addressing acute facial pain.

Awake neurosurgery: Advancements in microvascular decompression for trigeminal neuralgia

Background

The treatment landscape for trigeminal neuralgia (TN) involves various surgical interventions, among which microvascular decompression (MVD) stands out as highly effective. While MVD offers significant benefits, its success relies on precise surgical techniques and patient selection. In addition, the emergence of awake surgery techniques presents new opportunities to improve outcomes and minimize complications associated with MVD for TN.

Methods

A thorough review of the literature was conducted to explore the effectiveness and challenges of MVD for TN, as well as the impact of awake surgery on its outcomes. PubMed and Medline databases were searched from inception to March 2024 using specific keywords "Awake Neurosurgery," "Microvascular Decompression," AND "Trigeminal Neuralgia." Studies reporting original research on human subjects or preclinical investigations were included in the study.

Results

This review highlighted that MVD emerges as a highly effective treatment for TN, offering long-term pain relief with relatively low rates of recurrence and complications. Awake surgery techniques, including awake craniotomy, have revolutionized the approach to MVD, providing benefits such as reduced postoperative monitoring, shorter hospital stays, and improved neurological outcomes. Furthermore, awake MVD procedures offer opportunities for precise mapping and preservation of critical brain functions, enhancing surgical precision and patient outcomes.

Conclusion

The integration of awake surgery techniques, particularly awake MVD, represents a significant advancement in the treatment of TN. Future research should focus on refining awake surgery techniques and exploring new approaches to optimize outcomes in MVD for TN.

Effectiveness of gamma knife radiosurgery in the management of trigeminal neuralgia associated with multiple sclerosis: a systematic review and meta-analysis

BACKGROUND

Trigeminal neuralgia (TN) is a chronic condition characterized by intense facial pain akin to electric shocks, often associated with the trigeminal nerve. It can be either idiopathic or secondary, with multiple sclerosis (Ms) being a significant contributing factor. Non-responsive patients may opt for minimally invasive procedures, such as gamma knife radiosurgery (GKRS), which offers precise, non-invasive treatment and is frequently chosen as a primary approach. This meta-analysis evaluates the long-term efficacy of GKRS in TN management in Ms patients.

METHODS

We conducted a focused search across various databases. Inclusion criteria encompassed studies with ≥ 30 patients using GKRS for TN in Ms, reporting pertinent clinical outcomes. Primary outcomes assessed GKRS efficacy through Barrow Neurological Institute Pain scores. Secondary outcomes encompassed bothersome numbness, facial numbness, and recurrence. Data analysis employed OpenMeta, random effect models, and odds ratios with 95% confidence intervals. Heterogeneity was assessed using I2 statistics.

RESULTS

Fourteen studies with 752 cases of GKRS for TN were included. Regarding the outcomes, 83% of patients experienced a positive initial pain response, while the overall treatment success rate was 51%. Additionally, 19.6% of patients reported facial numbness, 4.1% experienced bothersome numbness, and 40% faced recurrence. The odds ratio for positive initial pain response was 0.83 (95% CI, 0.76-0.89), while for treatment success, it was 0.51 (95% CI, 0.379-0.639). Facial numbness had an odds ratio of 0.196 (95% CI, 0.130-0.262), bothersome numbness had an odds ratio of 0.041 (95% CI, 0.013-0.069), and recurrence had an odds ratio of 0.403 (95% CI, 0.254-0.551).

CONCLUSIONS

In conclusion, treating trigeminal neuralgia in multiple sclerosis patients remains challenging. GKRS shows promise, but customized treatment approaches tailored to individual patient characteristics are urgently needed to address the unique challenges of this condition.