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How to manage severe recurring pain on the right side of the forehead?

Q: I am having a problem of pain on my right hand side on my forehead again. Seven years ago I was operated at the Royal London Hospital, the reports read like this - "This man was referred to me because of persisting right sided trigeminal neuralgia in the V2 distribution. Examination findings were normal. His MRI scan however showed an ectatic vertebra basilar system with a loop of vessel impinging on the trigeminal nerve. I operated on him through a right sided posterior fossa craniotomy, performed a microvascular decompression of the right trigeminal nerve (Janetta procedure) at which time a loop of vessel was found distorting and displacing the middle portion of the trigeminal nerve. This was separated from the nerve and a spacer was interposed between the two. He made an excellent recovery post-operatively other than some minimal transient ataxia and had no significant recurrence of his pain. He is on the reduced doses of Carbamazepine having been on 1.2G per day pre-op and should not require further intervention." After coming to Tanzania from London a month after the operation, I started getting the pain again and was taking one tablet every 24 hours and was feeling better. This I had informed my doctor in London. This had continued for approximately three months after which I left the tablets and did not have any pains for almost a year. This happened once a year since then. But recently have developed the pain again and is very severe, tried to have the same tablets but did not find any difference, so now am having Tegretol 200 mg three times daily and am comfortable. Is there any permanent cure for my problem, and if yes, could I have your suggestions please?

A:I have gone through the details you have provided. I wish to inform you that in about 10-15% of cases there may a recurrence of pain after Microvascular decompression (MVD). There is no way of assessing this before the surgery. The best thing to do is to continue on medication if you are under control. The maximum doses that we can scale up with Tegretol for this condition could be even upto 1200 mg in a day for an adult weighing around sixty kgs. If there is a problem with taking drugs, then only a second option need be sought at the moment considering that there is no way of determining whether you can be completely pain free with a resurgery. There are many different methods of treating this disease but the best option is either Tegretol or MVD.

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