Trigeminal Neuralgia · Medical vs MVD vs Ablation

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] Medical response + imaging compression + age/comorbidity
   Medical response? MRI neurovascular compression? Age/comorbidity?
   • Newly diagnosed/not adequately treated medically → First-line medical
   • Medically refractory/intolerant + MRI neurovascular compression, can tolerate surgery → Microvascular decompression (MVD)
   • Medically refractory, elderly/comorbidity/no vascular compression/recurrence → Gamma knife/percutaneous lesioning
   • Secondary (multiple sclerosis/tumor compression) → Secondary → treat the cause
2. [End] First-line medical
   First-line carbamazepine/oxcarbazepine (gradual titration); if effective, maintain with hyponatremia/liver-renal monitoring; ineffective/intolerant → surgical assessment.
3. [End] Microvascular decompression (MVD)
   Medically refractory + MRI vascular compression, can tolerate general anesthesia → microvascular decompression (MVD, most durable, preserves facial sensation).
4. [End] Gamma knife/percutaneous lesioning
   Elderly/comorbidity/no vascular compression/recurrence → ablation: gamma knife radiosurgery or percutaneous (balloon/glycerol/radiofrequency) lesioning; less invasive but slower onset/higher recurrence than MVD, may cause facial numbness.
5. [End] Secondary → treat the cause
   Secondary (multiple sclerosis/tumor compression) → treat the cause (tumor resection/MS therapy) + symptomatic management; choose the procedure by etiology.

Source guidelines & references

• Trigeminal neuralgia management (AAN/EFNS; MVD vs ablation)

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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