When standard carbamazepine or oxcarbazepine regimens fail or cause intolerable side effects, managing refractory trigeminal neuralgia presents a daunting clinical challenge. Striking the right balance between medical escalation and surgical intervention requires a highly tailored approach based on pain characteristics, neurovascular compression, and patient comorbidities.In this focused session, we examine modern management pathways for refractory cases.

The discussion centers on navigating second- and third-line pharmacotherapy, evaluating candidacy for microvascular decompression (MVD), and selecting between ablative options like stereotactic radiosurgery (Gamma Knife) and percutaneous rhizotomy procedures. Clinicians will gain a structured framework for timing interventions, optimizing surgical referrals, and managing recurrent pain to restore patient quality of life.