Le traitement de la névralgie faciale est médical jusqu’à preuve du contraire, la Carbamazépine (Tégretol^*) étant depuis 1962 le médicament de loin le plus efficace, véritable « médicament miracle » pour les patients. D’autres anti-épileptiques peuvent être prescrits en cas d’intolérance au Tégretol^*. Lorsque le traitement médical échoue ou devient mal supporté, les options chirurgicales deviennent licites. La radiochirurgie stéréotaxique (Gammaknife) est alors la technique la moins agressive et ses indications sont légitimement de plus en plus nombreuses d’autant que statistiquement les résultats obtenus sont globalement équivalents à ceux obtenus avec les autres techniques radicales. Néanmoins, en raison d’un délai d’action parfois important de la radiochirurgie stéréotaxique pour l’amélioration ou la disparition de la douleur (supérieur à un mois en moyenne) les techniques radicales percutanées classiques et en particulier la thermocoagulation du Gasser ou la décompression microvasculaire neurochirurgicale représentent alors toujours des traitements de choix des formes hyperalgiques.

The primary treatment of ‘tic douloureux’ is first pharmacologic. The mainstays of the medical management are the anticonvulsants medications, the most effective one being, since 1962, Carbamazepine. For most patients Tegretol^* is a ‘Wonder drug’. Unfortunately, about half of trigeminal neuralgia (TN) sufferers eventually become dissatisfied with medical therapy because of incomplete control of pain or drug-related side-effects. In the past, patients with TN did not consider neurosurgical options until the pain or side-effects of medicines became unbearable because surgical procedures carried higher risks. These surgical options included peripheral nerve blocks, radiofrequency rhizotomy (RF), glycerol rhizolysis, balloon microcompression, microvascular decompression (MVD), and more recently gammaknife radiosurgery (GKRS). GKRS, the least invasive procedure, is a major advance in the treatment of TN and has in recent years become the treatment of choice for people unresponsive to medical therapy or intolerant of medications due to toxicity or allergic reactions. Success rates are similar to those of others interventional procedures and complications are limited mostly to facial numbness in less than 10% of cases. With GKRS patients no longer have to wait to be in agony in order to undergo neurosurgical interventions and this procedure should be carried out when the medication continues to have an effect but is less and less effective. Although a few patients experience immediate pain relief in some studies the onset of pain relief can be delayed for weeks or even months (mean 1month) and in those cases the patients afflicted with excruciating pain cannot afford to wait this longer and ‘salvage surgical therapy’ such as RF lesioning or MVD should be carried out without delay.