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

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.