Trigeminal neuralgia — SCE Neurology MCQ

Correct answer: D — Start carbamazepine with counselling and laboratory safety monitoring

The best answer is “Start carbamazepine with counselling and laboratory safety monitoring”. Carbamazepine is the established first-line treatment for classical trigeminal neuralgia; baseline and follow-up monitoring address hyponatraemia, hepatic injury and blood dyscrasias, while surgery is reserved for unsuitable or ineffective drug treatment. “Start regular opioid analgesia as disease-modifying treatment” is less appropriate because opioids generally perform poorly for paroxysmal trigeminal neuralgia and add dependence risk “Use indomethacin as a diagnostic requirement before treatment” is less appropriate because absolute indomethacin response defines other unilateral headache disorders rather than trigeminal neuralgia “Begin high-dose corticosteroids for presumed inflammatory neuritis” is less appropriate because the stereotyped triggerable phenotype does not imply inflammatory neuritis “Offer microvascular decompression before a tolerated medication trial” is less appropriate because an invasive procedure is not normally first when standard medication can be safely tried

Reference: Trigeminal neuralgia: a practical guide. https://pn.bmj.com/content/21/5/392