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Observational Study
. 2025 Oct 16;272(10):701.
doi: 10.1007/s00415-025-13447-9.

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

Jacob Worm  1   2 , Tone Bruvik Heinskou  3 , Per Rochat  4   5 , Jacob Bertram Springborg  4   5 , Emil Andonov Smilkov  6 , Lars Bendtsen  7   4 , Henrik Winther Schytz  7   4 , Stine Maarbjerg  7   4   8
Affiliations
Observational Study

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

Jacob Worm et al. J Neurol. .

Abstract

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.

Keywords: Anticonvulsants; Cohort studies; Facial pain; MDT; MVD; Multidisciplinary; Neurosurgery; Observational study; Pain management; Sex differences.

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Conflict of interest statement

Declarations. Conflicts of interest: JW serves as PI in an RCT sponsored by Noema Pharma, has received a scholarship grant from Copenhagen University Hospital Rigshospitalet, and travel support for congress attendance from Lundbeck and Novartis. LB has given lectures and served on the scientific advisory board for AbbVie, Pfizer, and Teva. HWS has received consultant fees from Lundbeck, Pfizer, AbbVie, Lilly, and Novartis.

Figures

Fig. 1
Fig. 1
Flowchart of inclusion. Individuals with classical and idiopathic trigeminal neuralgia were divided into two groups based on whether they were medically managed or underwent microvascular decompression. MVD microvascular decompression, STN secondary trigeminal neuralgia, PTTN post-traumatic trigeminal neuropathy, PIFP persistent idiopathic facial pain
Fig. 2
Fig. 2
Pain and medication status by sex in the two cohorts at 5-year follow-up. Distribution of outcomes in the microvascular decompression (MVD) and medical cohorts across four predefined categories: pain-free without medication, pain-free on medication, continued pain without medication, and continued pain on medication (a). Sex-stratified distributions within the MVD (b) and medical (c) cohorts are also shown, with proportions for men and women in each outcome category, illustrating differences in long-term treatment response across sex and treatment modality
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