# Five-year prospective outcomes of medical management and microvascular decompression in trigeminal neuralgia

## TL;DR

This study found that microvascular decompression surgery provides better long-term pain relief for trigeminal neuralgia compared to medical treatment over five years.

## Contribution

The study provides the first 5-year prospective comparison of medical and surgical treatments for trigeminal neuralgia.

## Key findings

- MVD achieved 59% pain-free without medication versus 19% with medical treatment.
- MVD reduced medication use and side effects compared to medical management.
- Male sex predicted better outcomes after MVD.

## Abstract

Trigeminal neuralgia is a severe facial pain disorder with major impact on quality of life. Long-term prospective data comparing medical and surgical treatments remain scarce. This study compared 5-year outcomes of medical management and microvascular decompression (MVD) and explored predictors of treatment response.

We conducted a prospective observational cohort study at a national referral center (2012–2019). Consecutive patients with classical or idiopathic trigeminal neuralgia underwent MRI, baseline assessment, and systematic 5-year follow-up. Treatment allocation (medical therapy or MVD) followed clinical evaluation and international guidelines. The primary outcome was categorized as pain-free without medication, pain-free with medication, continued pain without medication, or continued pain with medication.

Of 626 eligible patients, 227 completed follow-up (95 MVD, 132 medical). Pain-free without medication was achieved in 59% of MVD patients versus 19% of medically treated [relative risk (RR) 3.03, 95% confidence interval (CI) 1.67–5.50]. Pain-free with medication occurred in 1% after MVD versus 14% of the medical cohort (RR 0.16, 95% CI 0.04–0.69). Continued pain on medication was less frequent after MVD (22% vs 49%; RR 0.44, 95% CI 0.24–0.80). Male sex predicted excellent outcome after MVD (odds ratio 2.60, 95% CI 1.02–6.91). Postoperative hypoesthesia occurred in 23% and hearing impairment in 7%, while 55% of medically treated patients reported side effects.

MVD provided superior long-term pain relief, higher rates of medication-free pain freedom, and reduced medication use compared with medical management, supporting earlier surgical consideration in selected patients and emphasizing individualized, guideline-based care.

The online version contains supplementary material available at 10.1007/s00415-025-13447-9.