Summer 2012

Options for Trigeminal Neuralgia Patients

Given America's aging population, the prevalence of trigeminal neuralgia is likely to increase. And given the pain the condition causes and its resistance to long-term cures, offering patients a full menu of treatment options is critical.

Dr. Edward Chang

It's also helpful for patients to work with experienced clinicians when sorting through their various treatment options. "High volumes matter in that discussion — and in the results patients experience," says UCSF neurosurgeon Edward Chang, M.D.. He notes that UCSF Medical Center manages more than 300 trigeminal neuralgia patients each year.

From Medical Management to Surgical Menu

Medical management at UCSF usually begins with carbamazepine, titrated up from an initial small dose until the patient's pain is relieved. For some patients, gabapentin, baclofen and phenytoin can also be effective.

But medical management is not right for every patient, either because the pain breaks through the medication or because the side effects become too onerous. For such patients, there are multiple surgical options. Each year, physicians at UCSF treat more than 100 trigeminal neuralgia patients using one of the following procedures:

  • Microvascular decompression to separate the offending artery from the compressed nerve. "We perform two to three per week of this highly technical surgery," says Chang.
  • Radiosurgery, using either the Gamma Knife® or the CyberKnife® system.
  • Percutaneous rhizotomy, an outpatient procedure in which a needle is inserted through the cheek so the surgeon can conduct a thermal ablation of the nerve.

Tailoring Treatment to Patient Needs

"The key is to tailor the treatment," says Chang. "What are the indications, the risks and the needs of the patient, including their willingness and ability to undergo invasive procedures?"

Photo of neurovascular conflict

The most invasive procedure, microvascular decompression, is extremely effective at controlling the pain and has the best long-term results, says Chang. While very safe in experienced hands, it may not be appropriate for a patient who poses a higher surgical risk.

In other cases, the severity of symptoms and expectations of the patient determine what to use. Gamma Knife is a great noninvasive alternative, but it can result in facial numbness, and the biological effect may take some time, so if you need relief right away, it may not be the right choice," says Chang.

Thus, the value of a comprehensive center: If one procedure fails or is inappropriate for a patient's need, there are others. "You need backups and you also need smart care coordination, because even with the best treatment, this is a condition that tends to recur," says Chang. "So we partner closely with our community neurology and internist colleagues for long-term pain management. Together, we figure out how to best relieve these really suffering patients."

When to Refer for Trigeminal Neuralgia Surgery

Refer for surgery when:

  • Medications aren't working anymore.
  • Pain breaks through the medications.
  • Medication side effects are no longer tolerable.

For more information, contact Dr. Edward Chang at (415) 353-2241.

To contact UCSF Medical Center, visit

UCSF Medical Center is located at 505 Parnassus Avenue, San Francisco, CA 94143-0296.

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