Research Article | DOI: https://doi.org/10.31579/2642-973X/158
1Neurology Department, Faculty of Medicine - Mansoura University, Egypt.
2Anesthesia and Surgical Intensive Care Department, Faculty of Medicine - Mansoura University, Egypt.
*Corresponding Author: Osama Elshafei, Department of Neurology, Faculty of Medicine, Mansoura University, Mansoura 355111, Egypt. E-mail: Osama_elshafei@mans.edu.eg
Citation: Osama Elshafei, Mohammed Gomaa, Eiad Arafa, Hossam Egila, Mohamed Khateeb, (2020), Pulsed Radiofrequency in Treatment of Classic Trigeminal Neuralgia (Prolonged Duration Versus Higher Voltage): A Randomized Control Study, J. Brain and Neurological Disorders, 3(1): DOI:10.31579/2642-973X/158
Copyright: © 2020, Osama Elshafei. This is an open-access article distributed under the terms of The Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Received: 01 October 2020 | Accepted: 07 October 2020 | Published: 13 December 2020
Keywords: trigeminal neuralgia; pulsed radiofrequency; neuropathic pain; non-destructive treatment; randomized controlled trial; pain modulation; neuromodulation; quality of life
Background: Trigeminal neuralgia (TN) is a chronic facial pain condition marked by severe, electric shock-like episodes. First-line pharmacological treatments like carbamazepine often lose effectiveness or cause side effects, prompting the need for alternative therapies. Pulsed radiofrequency treatment (PRFT) has emerged as a non-destructive, neuromodulatory intervention for TN, but optimization of its parameters remains under investigation.
Objective: This study aimed to evaluate and compare the efficacy and safety of prolonged duration versus increased voltage settings in pulsed radiofrequency treatment for patients with classic trigeminal neuralgia.
Methods: A randomized controlled trial was conducted involving patients diagnosed with classic TN. Participants were divided into three groups: Group A received standard PRFT, Group B received PRFT with prolonged duration, and Group C received PRFT with increased voltage. Visual Analog Scale (VAS) scores, pain amplitude, and quality of life were assessed pre- and post-intervention.
Results: All three groups showed significant reduction in pain. VAS scores decreased from 6.87 to 2.33 in Group A, 7.20 to 1.87 in Group B, and 6.93 to 2.40 in Group C. Group B exhibited the greatest sustained pain relief and the most notable improvement in quality of life (p < 0.05). No serious complications were reported in any group.
Conclusions: Prolonging the duration of PRFT offers greater therapeutic benefit over increasing voltage in managing classic TN. This approach optimizes pain control while minimizing adverse effects, supporting its use as a preferred neuromodulatory strategy in resistant TN cases.
Trigeminal neuralgia (TN) is a debilitating neuropathic condition characterized by sudden, recurrent episodes of electric shock-like facial pain within one or more divisions of the trigeminal nerve. Despite being relatively rare—with an estimated prevalence of 12.6 to 27 per 100,000 individuals—it remains one of the most painful neurological disorders [1]. TN significantly impairs patients’ daily functioning, often leading to psychological distress and reduced quality of life. Pharmacological management, particularly with carbamazepine, is considered the first-line treatment. However, many patients eventually develop tolerance, experience severe side effects, or become refractory to medication, necessitating alternative therapeutic options [2].
Pulsed radiofrequency treatment (PRFT) has emerged as a minimally invasive, neuromodulatory intervention that avoids the tissue-destructive consequences associated with conventional radiofrequency thermocoagulation. PRFT modulates nerve function without causing axonal damage, offering sustained pain relief with fewer complications. Although PRFT is widely used, there is still no consensus regarding its optimal procedural parameters—particularly in terms of voltage intensity and duration of application [3].
Current literature lacks robust comparative trials exploring the effects of adjusting PRFT parameters, such as increasing voltage or extending the duration, on pain control and quality of life in patients with classic TN. Most studies focus either on a standard protocol or compare PRFT to other treatments, leaving a gap in evidence regarding internal optimization of the procedure itself [4, 5].
This study introduces a novel comparison between prolonged duration and increased voltage PRFT in a randomized controlled setting. It is among the first to directly evaluate these two parameter modifications side-by-side in the treatment of classic TN. By identifying the most effective and safe modulation strategy, this study seeks to refine PRFT protocols and enhance patient outcomes.
Accordingly, the aim of the study is to compare the efficacy and safety of prolonged duration versus increased voltage pulsed radiofrequency in the treatment of classic trigeminal neuralgia.
Patients And Methods
After approval from the Institutional Ethical Committee and obtaining informed written consent from all participants, this prospective study was conducted on 60 patients (subdivided into 3 groups each group 20 patient) diagnosed as classic TN according to the international headache society classification [6]. Patients were recruited from Neurology outpatient clinic in Mansoura university hospital from July 2016 to July 2018. All procedures adhered to the ethical standards of the Declaration of Helsinki.
Inclusion and Exclusion Criteria:
This study included adult patients aged between 18 and 70 years with a confirmed diagnosis of classic trigeminal neuralgia (TN) based on IHS (2013) criteria and normal MRI/MRA findings. Eligible patients had a VAS pain score ≥ 4 and were either refractory to at least three months of optimized medical therapy (including carbamazepine) or had developed intolerable drug side effects.
Exclusion criteria included symptomatic TN due to structural lesions (e.g., MS, tumors), local infection, bleeding disorders, prior invasive TN treatments, severe psychiatric illness, or substance abuse history, ensuring a homogenous sample with primary, medically resistant TN.
Study Procedures:
All participants underwent a standardized clinical protocol prior to and during the intervention. After comprehensive history taking, examination, and confirmation of diagnosis, patients were randomized into three groups using simple randomization:
• Group A (Standard PRF): Received pulsed radiofrequency at 45 volts for 120 seconds
• Group B (Prolonged Duration PRF): Received pulsed radiofrequency at 45 volts for 240 seconds
• Group C (Higher Voltage PRF): Received pulsed radiofrequency at 60 volts for 120 seconds
Pre-Procedure Evaluation
Each patient underwent the following assessments prior to intervention:
• Detailed medical and neurological history with emphasis on TN characteristics (site, frequency, severity, duration, trigger zones)
• Visual Analog Scale (VAS) scoring for baseline pain intensity
• Routine blood tests (CBC, coagulation profile)
• Neuroimaging (MRI brain) to exclude secondary TN (e.g., tumors, MS)
• Anesthetic fitness assessment for day-case procedure
Interventional Technique
The procedure was performed under strict aseptic conditions with patients lying supine and the head slightly extended. Continuous monitoring of ECG, pulse oximetry, and blood pressure was maintained throughout. Using C-arm fluoroscopy, the foramen ovale was visualized via a submental (caudo-cranial) view. The entry site was infiltrated with 1% lidocaine for local anesthesia.
A radiofrequency needle was inserted under tunnel vision technique toward the foramen ovale, with depth confirmed in alternating anteroposterior, lateral, and oblique views to avoid misplacement. Once the needle reached the target site near the Gasserian ganglion, sensory stimulation was initiated at 0.7V to elicit paresthesia in the target branch. If stimulation was non-specific or excessively diffuse, needle adjustments were made, followed by motor stimulation at double the sensory threshold to confirm absence of motor fiber involvement. After verifying proper placement, aspiration was performed to exclude blood or cerebrospinal fluid contamination before proceeding with PRF (Fig 1, 2).
Pulsed radiofrequency was administered using the NeuroTherm NT 1100 RF generator under different protocols for each group. Group A received two cycles of PRF at 45 volts for 2 minutes each, with a pulse width of 10 milliseconds and frequency of 4 Hz, and a cut-off needle tip temperature of 42°C. Group B received four cycles of the same parameters (i.e., 45V, 10ms, 4Hz, 42°C) to assess the effect of prolonged duration. Group C received two cycles at 60 volts, maintaining the same pulse width, frequency, and temperature, to evaluate the effect of increased voltage.
Figure 1: The needle entering the foramen ovale
Figure 2: Needle in position from lateral view
Post-Procedure Monitoring
Patients were observed immediately after the procedure and then followed up at 1 hour, 1 day, 1 week, 1 month, 6 months, and 12 months. At each time point, pain severity was re-assessed using the VAS scale. Clinical and electrophysiological assessment of trigeminal nerve function, including blink reflex testing, was repeated to monitor for post-intervention deficits. Quality of life was re-evaluated using the RAND 36-Item Health Survey at 12 months post-procedure to determine long-term functional outcomes. Additionally, all patients were monitored for procedure-related complications, including local edema, sensory deficits, or facial muscle weakness.
Statistical analysis: The collected data were coded, processed and analyzed using the SPSS (Statistical Package for Social Sciences) version 15 for Windows® (SPSS Inc, Chicago, IL, USA). Qualitative data was presented as number and percent. Comparison between groups was done by Chi-Square test. Quantitative data was presented as mean ± SD. Paired t-test was used for comparison within groups. Student t-test was used to compare between two groups. F-test (One Way Anova) was used to compare between more than two groups. P < 0.05 was considered to be statistically significant.
Case (1)
Female patient aged 39 years old presented with left trigeminal neuralgia in the distribution of the mandibular branch in the last 10 months. Neurological examination of the patient was within normal and VAS score was 7. Blink reflex was normal. MRI and MRA showed no evidence of secondary causes of TN or vascular contact (Fig. 3).
The patient received two cycles of PRF, each one for 2 minutes at 45 V (Fig. 4). VAS scores was followed up after 1 hour, 1 day, 1 week, 1month, 6 months and 12 months and was 2, 2, 3, 3, 2, 3 respectively.
Quality of life questionnaire results was improved after the intervention as regard: role limitation due to emotional problem (from 33 to 67), energy (from 45 to 55), emotional wellbeing (from 48 to 60), social functioning (from 50 to 75), pain (from 45 to 90), general health (from 25 to 50) and the change since previous year was 75.
Figure 3: Normal MRI brain
Figure 4: Lateral view showing the needle in position
Demographic data
This study was conducted on 60 Patients with trigeminal neuralgia who met the inclusion criteria were recruited including 22 males (36.7%) and 38 females (63.3%). During the follow up period 10 patients were lost (1 patient died and the cause of death was not related to TN or the intervention, 4 patients refused to continue the follow up and 5 patients did not show up for follow up).
The mean age was 49.13 ± 6.81 years (minimal age was 37 years and the maximal age was 60 years). The mean pain duration was 31.37 ± 24.62 months (with minimal duration of 6 months and maximal duration of 120 months) (Table 1).
Number of patients | Minimum | Maximum | Mean ± SD | |
| Age (years) | 60 | 37 | 60 | 49.13 ± 6.81 |
| Pain Duration (months) | 60 | 6 | 120 | 31.37 ± 24.62 |
Table 1: Age and pain duration among all the patients
Pain was localized to the right side in 34 patients (56.7%) and to the left side in 26 patients (43.3%). Pain was distributed to V1 in 4 patients (6.67%), V2 in 8 patients (13.33%), V3 in 36 patients (60%), V2 and V3 in 10 patients (16.67%), V1, V2 and V3 in 2 patients (3.33%).
Patients were randomly distributed into three groups A, B and C. The mean age of the patients in group A was 49.2 ± 6.94 years, group B was
48.9 ± 5.88 years while group C was 49.3 ± 7.81 years with no statistically significant difference between them P=0.982. The mean pain duration from onset in group A was 39.8 ± 33.26 months, in group B was 28.3 ± 19.26 while in group C was 26 ± 17.04 months with no statistically significant difference between the three groups P=0.166 (Table 2).
Group A (n = 20) Mean ± SD | Group B (n = 20) Mean ± SD | Group C (n = 20) Mean ± SD |
F P | |
| Age(years) | 49.2± 6.94 | 48.9± 5.88 | 49.3± 7.81 | 0.018 0.982 |
| Duration(months) | 39.8 ± 33.26 | 28.3 ± 19.26 | 26 ± 17.04 | 1.856 0.166 |
Table 2: Age and pain duration among the three groups
Group A included 20 patients (4 males and 16 females), Group B included 20 patients (8 males and 12 females) and Group C included 20 patients (10 males and 10 females) with no statistically significant difference between the three groups P=0.134 (Table 3).
Group A (N = 20) | Group B (N = 20) | Group C (N = 20) |
2 P | |||||
| No | % | No | % | No | % | |||
| Male | 4 | 20% | 8 | 40% | 10 | 50% | 4.019 | 0.134 |
| Female | 16 | 80% | 12 | 60% | 10 | 50% | ||
Table 3: Sex distribution among the three groups’ patients
In group A, pain was localized to the right side in 12 patients (60%) and to the left side in 8 patients (40%). In group B, also pain was localized to the right side in 12 patients (60%) and to the left side in 8 patients (40%). In group C pain was localized to the right side in 10 patients (50%) and to the left side in 10 patients (50%) with no statistically significant difference between the groups P=0.762 (Table 4).
Group A (n = 20) | Group B (n = 20) | Group C (n = 20) |
2 P | |||||
| No | % | No | % | No | % | |||
| Right | 12 | 60% | 12 | 60% | 10 | 50% | 0.543 | 0.762 |
| Left | 8 | 40% | 8 | 40% | 10 | 50% | ||
Table 4: Affection of the right or left side among the three groups
In group A, Pain was distributed in 16 patients to V3 (80%), in 2 patients to V2 and V3 (10%) and in 2 patients to V2 (10%). In group B pain was distributed in 2 patients to V1 (10%), 2 patients to V2 (10%), 8 patients to V3 (40%), in 6 patients to V2 and V3 (30%) and in 2 patients to V1,
V2 and V3 (10%). While in group C, pain was distributed in 2 patients to V1 (10%), in 4 patients to V2 (20%), 12 patients to V3 (60%) and in 2 patients to V2 and V3 (10%). There was no statistically significant difference between the three groups as regard the affected side or the affected branch P=0.085 (Table 5).
V1 | Group A (n = 20) | Group B (n = 20) | Group C (n = 20) |
2 P | ||||
| No | % | No | % | No | % | |||
| 0 | 0% | 2 | 10% | 2 | 10% |
13.867 0.085 | ||
| V2 | 2 | 10% | 2 | 10% | 4 | 20% | ||
| V3 | 16 | 80% | 8 | 40% | 12 | 60% | ||
| V2,3 | 2 | 10% | 6 | 30% | 2 | 10% | ||
| V1,2,3 | 0 | 0% | 2 | 10% | 0 | 0% | ||
Table 5: Pain distribution among the three groups
Visual analogue pain scale scores before the intervention
Visual analogue scale mean score among all the patients was 7.3 ±1.23 with the maximal score was 10 and the minimal score was 5. Visual analogue scale mean score of group A was 6.9 ± 1.17, group B mean score was 7.5 ± 1.05 while group C was 7.5 ± 1.4 with no statistically significant difference between the three groups P=0.204 (Table 6).
GroupA Mean± SD | GroupB Mean± SD | GroupC Mean± SD | F P All patients Mean ± SD | ||
| VAS | 6.9 ± 1.17 | 7.5 ± 1.05 | 7.5 ± 1.4 | 1.632 0.204 | 7.3 ± 1.23 |
Table 6: Pre-intervention VAS scores
Visual analogue pain scale scores follow up after the intervention
In group A patient, with the total number of 20 patients completed the follow up, VAS mean score 1hour after the intervention was 1.1 ± 0.72 with mean pain amplitude reduction of 5.8 ± 1.2 (84.18%) showing highly statistically significance P= 0.000. One day after the intervention VAS mean score was 2 ± 1.38 with mean pain amplitude reduction of 4.9 ± 1.48 (71.26%) showing highly statistically significance P= 0.000.
On follow up after 1 week, VAS mean score was 2.8 ± 1.2 with mean pain amplitude reduction of 4.1 ± 1.25 (59.52%) with highly statistically significance P= 0.000. After 1 month, VAS mean score of group A was 3 ± 1.3 with mean pain amplitude reduction of 4.1 ± 1.25 (57.78%) which was highly statistically significance P= 0.000.
After 6 months VAS mean score was 3.1 ± 1.41 with mean pain amplitude reduction of 3.8 ± 1.01 (56.09%) showing highly statistically significance P= 0.000. After 12 months, VAS mean score was 4.2 ± 1.51 with mean pain amplitude reduction of 2.7 ± 1.22 (39.53%) showing highly statistically significance P= 0.000 (Table 7).
| No of patients | VAS Mean± SD |
P | Painamplitude reduction Mean ± SD | P | Painamplitude reduction Percentage | |
| 1hr | 20 | 1.1 ± 0.72 | 0.000 | 5.8 ±1.2 | 0.000 | 84.18% |
| 1d | 20 | 2 ± 1.38 | 0.000 | 4.9 ± 1.48 | 0.000 | 71.26% |
| 1w | 20 | 2.8 ±1.2 | 0.000 | 4.1 ± 1.25 | 0.000 | 59.52% |
| 1m | 20 | 3 ± 1.3 | 0.000 | 3.9 ± 1.25 | 0.000 | 57.78% |
| 6m | 20 | 3.1 ± 1.41 | 0.000 | 3.8 ± 1.01 | 0.000 | 56.09% |
| 12m | 20 | 4.2 ± 1.51 | 0.000 | 2.7 ± 1.22 | 0.000 | 39.53% |
Table 7: VAS and amplitude reduction among Group A patients
In group B patients, 1hour after the intervention (patients’ number =20), VAS mean score was 0.7 ± 0.66 with mean pain amplitude reduction of 6.8 ± 0.77 (91.3%) showing highly statistically significance P= 0.000. VAS mean score 1 day after the intervention (patients’ number =20), was 1.6 ± 0.82 with mean pain amplitude reduction of 5.9 ± 0.55 (79.56%) showing highly statistically significance P= 0.000.
VAS mean score of group B patients after 1 week (patients’ number =18), was 2.22 ± 1.06 with mean pain amplitude reduction of 5.33 ± 0.84 (71.42%) showing highly statistically significance P= 0.000. After 1
month (patients’ number =18), VAS mean score was 3 ± 0.97 with mean pain amplitude reduction of 4.56 ± 0.7 (60.98%) showing highly statistically significance P= 0.000.
After 6 months, VAS mean score of group B (patients’ number =16), was 2.88 ± 0.81 with mean pain amplitude reduction of 4.75 ± 1 (62.35%) showing highly statistically significance P= 0.000. After 12 months VAS mean score of group B (patients’ number =16), was 3.88 ± 1.09 with mean pain amplitude reduction of 3.75 ± 0.86 (49.5%) showing highly statistically significance P= 0.000 (Table 8).
| No of patients | VAS Mean± SD |
P | Painamplitude reduction Mean ± SD |
P | Painamplitude reduction Percentage | |
| 1hr | 20 | 0.7 ± 0.66 | 0.000 | 6.8 ± 0.77 | 0.000 | 91.3% |
| 1d | 20 | 1.6 ± 0.82 | 0.000 | 5.9 ± 0.55 | 0.000 | 79.56% |
| 1w | 18 | 2.22± 1.06 | 0.000 | 5.33± 0.84 | 0.000 | 71.42% |
| 1m | 18 | 3 ± 0.97 | 0.000 | 4.56 ±0.7 | 0.000 | 60.89% |
| 6m | 16 | 2.88± 0.81 | 0.000 | 4.75 ±1 | 0.000 | 62.35% |
| 12m | 16 | 3.88± 1.09 | 0.000 | 3.75± 0.86 | 0.000 | 49.5% |
Table 8: VAS and amplitude reduction among group B patients
In group C patients, VAS mean score 1hour after the intervention (patients’ number =20) was 1.3 ± 0.66 with mean pain amplitude reduction of 6.2 ± 1.11 (83.32%) showing highly statistically significance P= 0.000. VAS mean score 1 day after the intervention (patients’ number =20), was 2.3 ± 1.03 with mean pain amplitude reduction of 5.2 ± 0.89 (70.15%) showing highly statistically significance P= 0.000.
VAS mean score of group C patients 1 week after the intervention (patients’ number =18), was 2.5 ± 1.46 with mean pain amplitude reduction of 5.13 ± 0.96 (68.73%) showing highly statistically significance P= 0.000.
After 1 month (patients’ number =18), VAS mean score was 3.38 ± 1.86 with mean pain amplitude reduction of 4.25 ± 1 (57.65%) showing highly statistically significance P= 0.000.
After 6 months (patients’ number =14), VAS mean score of group C was 3.14 ± 1.51 with mean pain amplitude reduction of 4.14 ± 0.86 (57.35%) showing highly statistically significance P= 0.000. After 12 months (patients’ number =14), VAS mean score was 4.71 ± 1.98 with mean pain amplitude reduction of 2.57 ± 1.34 (36.58%) showing highly statistically significance P= 0.000 (Table 9)
| No of patients | VAS Mean ± SD |
P | Pain amplitude reduction Mean ± SD |
P | Pain amplitude reduction Percentage | |
| 1hr | 20 | 1.3 ± 0.66 | 0.000 | 6.2 ± 1.11 | 0.000 | 83.32% |
| 1d | 20 | 2.3 ± 1.03 | 0.000 | 5.2 ± 0.89 | 0.000 | 70.15% |
| 1w | 18 | 2.5 ± 1.46 | 0.000 | 5.13 ± 0.96 | 0.000 | 68.73% |
| 1m | 18 | 3.38 ± 1.86 | 0.000 | 4.25 ± 1 | 0.000 | 57.65% |
| 6m | 14 | 3.14 ± 1.51 | 0.000 | 4.14 ± 0.86 | 0.000 | 57.35% |
| 12m | 14 | 4.71 ± 1.98 | 0.000 | 2.57 ± 1.34 | 0.000 | 36.58% |
Table 9: VAS and amplitude reduction among group C patients
By comparing the VAS scores between the three groups 1hour after the intervention, Group B showed the lower VAS score mean (0.7 ± 0.66) with statistically significant difference from group A (1.1 ± 0.72) and C (1.3 ± 0.66) (P=0.022). 1 day after the intervention VAS mean scores showed lower VAS mean score in group B patients (1.6 ± 0.82) than those in group A (2 ± 1.38) and group C (2.3 ± 1.03) (P=0.140).
After 1 week, group B patients showed lower VAS scores (2.22 ± 1.06) than group A (2.8 ± 1.2) and group C (2.5 ± 1.46) (P=0.363). Also, after
1 month, group B patients showed lower VAS scores (3 ± 0.97) than group A (3 ± 1.3) and group C (3.38 ± 1.86) (P=0.669).
After 6 months, group B patients showed lower VAS scores (2.88 ± 0.81) than group A (3.1 ± 1.41) and group C (3.14 ± 1.51) (P=0.820). Also after 12 months, group B patients showed lower VAS scores (3.88 ± 1.09) than group A (4.2 ± 1.51) and group C (4.71 ± 1.98) (P=0.336) (Table 10).
Group A Mean± SD | Group B Mean± SD | Group C Mean± SD | F P | ||
| Vas1hr | 1.1 ± 0.72 | 0.7 ± 0.66 | 1.3 ± 0.66 | 4.061 | 0.022* |
| VAS1d | 2 ± 1.38 | 1.6 ± 0.82 | 2.3 ± 1.03 | 2.038 | 0.140 |
| VAS1w | 2.8 ±1.2 | 2.22± 1.06 | 2.5 ± 1.46 | 1.032 | 0.363 |
| VAS1m | 3 ± 1.3 | 3 ± 0.97 | 3.38± 1.86 | 0.405 | 0.669 |
| VAS6m | 3.1 ± 1.41 | 2.88± 0.81 | 3.14± 1.51 | 0.199 | 0.820 |
| VAS12m | 4.2 ± 1.51 | 3.88± 1.09 | 4.71± 1.98 | 1.117 | 0.336 |
Table 10: VAS scores of the three groups after intervention
By comparing the three groups as regard the pain amplitude reduction 1 hour after the intervention, group B showed the greater pain amplitude reduction (6.8 ± 0.77) followed by group C (6.2 ± 1.11) then group A with the least pain amplitude reduction (5.8 ± 1.2) (P=0.013). Also 1 day after the intervention, group B showed pain amplitude reduction (5.9± 0.55) more than group C (5.2 ± 0.89) and group A (4.9 ± 1.48) and (P= 0.012).
One week after the intervention, there was statistically significant pain amplitude reduction in group B (5.33 ± 0.84) in comparison to group C (5.13 ± 0.96) and group A (4.1 ± 1.25) (P= 0.001).
On follow up after 1 month, group B showed pain reduction (3.9 ± 1.25) more than group C (4.25 ± 1) and group A (3.9 ± 1.25), but there was no statistically significant difference between the three groups (P= 0.152).
After 6 months, there was significant pain amplitude reduction in group B (4.75 ± 1) more than group C (4.14 ± 0.86) and group A (3.8 ± 1.01) (P= 0.019).
After 12 months, there was statistically significant pain amplitude reduction in group B (3.75 ± 0.86) in comparison to group A (2.7 ± 1.22) and C (2.57 ± 1.34) (P= 0.011) (Table 11).
amplitude reduction | Group A Mean ± SD | Group B Mean ± SD | Group C Mean ± SD | F | P |
| 1hr | 5.8 ±1.2 | 6.8 ± 0.77 | 6.2 ± 1.11 | 4.688 | 0.013* |
| 1d | 4.9 ± 1.48 | 5.9 ± 0.55 | 5.2 ± 0.89 | 4.780 | 0.012* |
| 1w | 4.1 ± 1.25 | 5.33± 0.84 | 5.13± 0.96 | 7.619 | 0.001* |
| 1m | 3.9 ± 1.25 | 4.56 ±0.7 | 4.25 ±1 | 1.958 | 0.152 |
| 6m | 3.8 ± 1.01 | 4.75 ±1 | 4.14± 0.86 | 4.327 | 0.019* |
| 12m | 2.7 ± 1.22 | 3.75± 0.86 | 2.57± 1.34 | 5.017 | 0.011* |
Table 11: Pain amplitude reduction in the three groups
Quality of life scores
In group A, there was non-significant difference as regard physical functioning scores before (93.89 ± 5.83) and after intervention (94.44 ± 6.16) (P=0.163). Also, there was non-significant difference as regard the role limitation due to physical health before (77.78 ± 25.57) and after (86.11 ± 12.78) intervention (P=0.055).
There was significant improvement in the role limitation due to emotional problems from mean score of 44.56 ± 28.19 to 66.67 ± 28.15 (P=0.001). Also, there was significant improvement in energy and fatigue mean scores from 41.11 ± 12.55 to 66.67 ± 28.15 (P=0.001).
As regard emotional wellbeing scores, it improved from 41.78 ± 13.18 before the intervention to 49.33 ± 13.44 after it (P=0.001). A highly significant improvement (P<0.001) in other scores was recorded as regard social functioning (from 40.33 ± 14.66 to 68.22 ± 12.34), pain score (from 33 ± 12.27 to 64.22 ± 13.34), general health (from 38.89 ± 17.62 to 49.44 ± 14.64) and change from previous year score (from 41.67 ± 12.13 to 83.33 ± 12.13) (Table 12).
Pre Post Group A (n = 20) (n = 20) t P Mean ± SD Mean ± SD | ||||
| Physical Functioning | 93.89 ± 5.83 | 94.44 ± 6.16 | 1.458 | 0.163 |
Role Limitations due to physical health | 77.78 ± 25.57 | 86.11 ± 12.78 | 2.062 | 0.055 |
Role Limitations due to emotional problems | 44.56 ± 28.19 | 66.67 ± 28.15 | 4.102 | 0.001* |
| Energy Fatigue | 41.11 ± 12.55 | 47.78 ± 10.88 | 4.123 | 0.001* |
| Emotional well being | 41.78 ± 13.18 | 49.33 ± 13.44 | 3.847 | 0.001* |
| Social Functioning | 40.33 ± 14.66 | 68.22 ± 12.34 | 11.744 | <0> |
| Pain | 33 ± 12.27 | 64.22 ± 13.34 | 14.750 | <0> |
| General Health | 38.89 ± 17.62 | 49.44 ± 14.64 | 4.299 | <0> |
Change from previous year | 41.67 ± 12.13 | 83.33 ± 12.13 | 10.308 | <0> |
Table 12: Quality of life scores in group A patients
Among group B patients, there was no difference in the mean score of the physical functioning before and after intervention (81.88 ± 18.96). There was significant improvement as regard the role limitation due to physical health before (56.25 ± 33.54) and after (68.75 ± 30.96) intervention (P=0.015).
There was highly significant improvement (P<0.001) as regard other scores, the role limitation due to emotional problems (from 50 ± 17.56 to 79.38 ± 16.5), energy and fatigue (from 31.25 ± 10.57 to 46.25 ± 12.32) emotional wellbeing scores (from 31.5 ± 13.61 to 50.5 ± 12.72), social functioning (from 29.88 ± 17 to 78.38 ± 8.64), pain score (from 23.25 ± 16.63 to 70.63 ± 12.66), general health (from 30.5 ± 17.32 to 40 ± 17.13) and change from previous year score (from 31.25 ± 17.08 to 87.5 ± 12.91) (Table 13).
Pre Post Group B (n = 16) (n = 16) t P Mean ± SD Mean ± SD | ||||
| Physical Functioning | 81.88 ± 18.96 | 81.88 ± 18.96 | 0.0 | 1.0 |
Role Limitations due to physical health | 56.25 ± 33.54 | 68.75 ± 30.96 | 2.739 | 0.015* |
Role Limitations due to emotional problems | 50 ± 17.56 | 79.38 ± 16.5 | 5.660 | <0> |
| Energy Fatigue | 31.25 ± 10.57 | 46.25 ± 12.32 | 6.211 | <0> |
| Emotional well being | 31.5 ± 13.61 | 50.5 ± 12.72 | 6.154 | <0> |
| Social Functioning | 29.88 ± 17 | 78.38 ± 8.64 | 11.045 | <0> |
| Pain | 23.25 ± 16.63 | 70.63 ± 12.66 | 17.000 | <0> |
| General Health | 30.5 ± 17.32 | 40 ± 17.13 | 19.170 | <0> |
Change from previous year | 31.25 ± 17.08 | 87.5 ± 12.91 | 10.510 | <0> |
Table 13: Quality of life scores in group B patients
Among group C patients, there was no difference in the mean score of the physical functioning before and after intervention (86.88 ± 24.21) and the role limitation due to physical health before and after intervention (60 ± 31.62).
There was significant improvement in energy and fatigue mean scores from 33.75 ± 14.08 to 41.25 ± 11.18 (P=0.018) and emotional wellbeing score from 41.13 ± 18.51 to 49 ± 8.7 (P=0.016).
There was highly significant improvement (P<0.001) as regard other scores, the role limitation due to emotional problems (from 45.63 ± 24.14 to 66.88 ± 17.3), social functioning (from 39.38 ± 17.67 to 67.38 ± 12.87), pain score (from 30.5 ± 17.59 to 62.5 ± 11.89), general health (from 38.75 ± 16.28 to 44.38 ± 14.48) and change from previous year score (from 31.88 ± 15.48 to 81.25 ± 11.18) (Table 14).
Pre Post Group C (n = 14) (n = 14) T P Mean ± SD Mean ± SD | ||||
| Physical Functioning | 86.88 ± 24.21 | 86.88 ± 24.21 | 0.0 | 1.0 |
Role Limitations due to physical health | 60 ± 31.62 | 60 ± 31.62 | 0.0 | 1.0 |
Role Limitations due to emotional problems | 45.63 ± 24.14 | 66.88 ± 17.3 | 5.000 | <0> |
| Energy Fatigue | 33.75 ± 14.08 | 41.25 ± 11.18 | 2.666 | 0.018* |
| Emotional well being | 41.13 ± 18.51 | 49 ± 8.7 | 2.700 | 0.016* |
| Social Functioning | 39.38 ± 17.67 | 67.38 ± 12.87 | 7.324 | <0> |
| Pain | 30.5 ± 17.59 | 62.5 ± 11.89 | 14.287 | <0> |
| General Health | 38.75 ± 16.28 | 44.38 ± 14.48 | 4.700 | <0> |
Change from previous year | 31.88 ± 15.48 | 81.25 ± 11.18 | 13.217 | <0> |
Table 14: Quality of life scores in group C patients
By comparing the three groups scores there was non-statistically significant difference in the scores as regard physical functioning, role limitations due to emotional problems, pain, general health and change from previous year either the pre-interventional scores (P=0.116, 0.581, 0.416, 0.286, 0.069 respectively) or the post-interventional scores (P=0.095, 0.169, 0.170, 0.214, 0.338 respectively).
As regard role limitation due to physical health, there was non- statistically significant difference between the pre-interventional scores of the three groups (P=0.08), while there was statistically significant difference between the post-interventional scores (P=0.013). Group A showed the highest score while group C showed the lowest score.
As regard the energy and fatigue and the emotional wellbeing, there was statistically significant difference between the pre-interventional scores (P=0.023, 0.025 respectively) with group B showed the lowest score while group A showed the highest score. While there was non-statistically significant difference between the three groups as regard the post- interventional scores (P=0.239, 0.932 respectively).
As regard the social functioning, there was non-statistically significant difference between the pre-interventional scores (P=0.160), while there was statistically significant difference between the three groups as regard the post-interventional scores (P=0.015). With group B showed the highest score and group C showed the lowest score (Table 15).
| Pre-intervention scores Post-intervention scores | ||||
| F | P | F | P | |
| Physical Functioning | 2.254 | 0.116 | 2.467 | 0.095 |
Role Limitations due to physical health | 2.667 | 0.080 | 4.695 | 0.013* |
Role Limitations due to emotional problems | 0.548 | 0.581 | 1.845 | 0.169 |
| Energy/ Fatigue | 4.027 | 0.023* | 1.476 | 0.239 |
| Emotional well being | 3.949 | 0.025* | 0.071 | 0.932 |
| Social Functioning | 1.895 | 0.160 | 4.621 | 0.015* |
| Pain | 0.890 | 0.416 | 1.840 | 0.170 |
| General Health | 1.282 | 0.286 | 1.596 | 0.214 |
Change from previous year | 2.817 | 0.069 | 1.111 | 0.338 |
Table 15: Comparison between the pre and post-interventional scores of the three groups as regard the quality of life questionnaire
Complications of the procedure:
Four patients developed local mild edema at the site of needle puncture which was resolved within hours using ice packs. No other complications were reported after the intervention or any of the patients needed hospitalization.
Trigeminal neuralgia (TN) is a relatively common chronic neuropathic condition, presenting with recurrent episodes of intense, burning, or electric shock-like pain distributed along one or more branches of the trigeminal nerve [8]. The diagnosis of TN is predominantly clinical, as there remains a lack of objective diagnostic investigations. However, magnetic resonance imaging (MRI) plays a critical role in identifying secondary causes such as multiple sclerosis, which may present with similar symptoms [9].
First-line treatment for TN is pharmacological, primarily relying on anticonvulsants. Carbamazepine remains the most effective and commonly prescribed agent. Additional options include baclofen, lamotrigine, phenytoin, gabapentin, and sodium valproate, especially when carbamazepine is not tolerated or fails to achieve adequate pain control [9]. In cases where medical therapy is ineffective, interventional management becomes necessary. These interventions are typically classified into two main categories: ablative and restorative techniques [10]. Ablative procedures, such as glycerol injections, radiofrequency thermal coagulation, balloon compression, and gamma knife radiosurgery, focus on lesioning the nerve to interrupt pain signals. While often effective in providing pain relief, they carry a notable risk of sensory loss due to nerve damage. Restorative procedures aim to preserve nerve integrity; these include microvascular decompression and pulsed radiofrequency (PRF) therapy [11].
Pulsed radiofrequency is fundamentally different from conventional radiofrequency in that it applies short bursts of high-frequency electrical current, allowing time for tissue cooling between pulses. This prevents thermal destruction of neural tissue and instead creates a neuromodulatory effect by altering C-fiber signaling, thereby achieving analgesia without structural damage or deafferentation [12]. For this reason, PRF is considered a safer alternative, particularly in managing idiopathic TN.
In our study, a clear female predominance (63.3%) was noted among TN patients, compared to males (36.7%). This finding aligns with previous epidemiological research: Katusic et al. [13] reported a significantly higher incidence in females (5.9 per 100,000) compared to males (3.4 per 100,000). Similarly, Bennetto et al. [14] observed that 62% of their TN patients were female. Other studies have corroborated these gender differences, such as Jainkittivong et al. [15], Teixeira et al. [16], and De Siqueira et al. [17], all reporting female predominance in TN cohorts. One proposed explanation involves postmenopausal osteoporosis in women, which can result in progressive basilar impression and subsequent compression of the trigeminal nerve [18].
Regarding age distribution, the mean age of TN onset in our study was 49.13 ± 6.81 years, with the youngest patient being 37 years and the oldest 60 years. This trend is supported by literature, with Jainkittivong et al. [15] stating the peak incidence occurs between 50 and 69 years. Likewise, Maarbjerg et al. [19] reported a mean onset age of 52.9 years and an average age of 62.5 years. Teixeira et al. [16] and De Siqueira et al. [17] found mean ages of 60.8 and 54 years, respectively. The increasing incidence with age has been attributed to age-related anatomical changes, such as elongation of cerebral arteries and brain sagging, leading to pulsatile compression of the trigeminal nerve [18].
Our findings also showed that TN more frequently affected the right side of the face (56.7%) compared to the left (43.3%). This observation is consistent with those of Maarbjerg et al. [19], who found right-sided involvement in 56% of patients. Jainkittivong et al. [15] reported a right-to-left side pain ratio of 1.8:1. Similarly, Siqueira et al. [20] and Bangash [21] documented higher prevalence on the right side, with Bangash noting that 64% of patients experienced right-sided pain. The anatomical rationale for this asymmetry remains speculative, but one plausible explanation is that the foramina rotundum and ovale—through which the maxillary and mandibular branches of the trigeminal nerve pass—are often narrower on the right side, potentially increasing the likelihood of nerve entrapment [22].
In our study, we observed that pain was most commonly distributed along the mandibular division (V3) in 60% of the patients, followed by the maxillary division (V2) in 13.33%, and the combined involvement of V2 and V3 in 16.67% of the cases. Pain localized exclusively to the ophthalmic division (V1) occurred in 6.67% of patients, while simultaneous involvement of all three branches (V1, V2, and V3) was seen in only 3.33%. These findings are consistent with previous literature. Bangash [21] reported that the mandibular division was the most frequently affected (55%), followed by the maxillary (39%) and ophthalmic (6%) divisions. That study also identified combined V2 and V3 involvement in 9% of cases, with no patients exhibiting pain across all three divisions. De Siqueira et al. [17] similarly found that the mandibular and maxillary branches were individually affected in 29.5% of cases each, while combined involvement was seen in 20.5%. Anatomically, entrapment of the maxillary and mandibular nerves as they pass through the foramina rotundum and ovale may underlie these distribution patterns [22]. However, Bangash [21] noted that no definitive explanation has been established for the selective involvement of certain trigeminal branches.
Regarding treatment efficacy, our analysis of Group A patients—who underwent pulsed radiofrequency (PRF) using the standard technique—revealed a highly significant reduction in pain amplitude. The most notable improvement was observed in the first hour (84.18%) and on the first day (71.26%) post-intervention. Pain reduction remained substantial at one month (57.78%) and six months (56.09%), though it decreased to 39.53% by twelve months. Nevertheless, all reductions remained statistically significant when compared to baseline pain scores. These results align with the findings of Van Zundert et al. [23], who first introduced PRF as a therapeutic alternative to conventional radiofrequency (CRF). They reported excellent pain relief in four out of five patients for an average duration of 17.5 months.
Similarly, Luo et al. [24] found that standard PRF resulted in satisfactory outcomes in 41% of TN patients at six months post-treatment, though the effectiveness dropped to 19
Despite its strengths, this study has some limitations. The sample size, while adequate for preliminary analysis, remains relatively small for generalizing findings. Follow-up was limited to 12 months, which may not fully capture long-term recurrence or delayed adverse effects. The study was also limited to patients with classic TN without any MRI/MRA abnormalities, excluding patients with secondary TN, which narrows the scope of applicability. Finally, blinding and randomization were not described in detail, which could introduce selection or performance bias.
This study concludes that PRF, particularly when applied with prolonged duration or increased voltage, is a highly effective and well-tolerated intervention for pain relief in classic trigeminal neuralgia. Among the three groups, the prolonged duration technique yielded the most sustained pain reduction, followed by high-voltage PRF. These techniques showed statistically significant improvements in pain scores and quality of life, with minimal complications reported. The study supports the notion that parameter modification in PRF can enhance its therapeutic efficacy without compromising safety.
Based on the findings, it is recommended that clinicians consider using modified PRF parameters—particularly prolonged application duration—for patients with medically refractory classic TN. Future research should include larger, multicenter randomized controlled trials with longer follow-up periods to validate these findings and establish standardized PRF protocols.
Abbreviation Full Term
TN Trigeminal Neuralgia
PRF Pulsed Radiofrequency
PRFT Pulsed Radiofrequency Treatment
VAS Visual Analog Scale
MRI Magnetic Resonance Imaging
MRA Magnetic Resonance Angiography
IHS International Headache Society
SD Standard Deviation
SPSS Statistical Package for Social Sciences
RF Radiofrequency
The authors would like to thank the patients who participated in this study, and the medical staff at Mansoura University Hospital for their support during recruitment and procedures. Special thanks to the Department of Neurology and Anesthesia for their collaboration and clinical assistance.
The authors declare no conflicts of interest regarding the publication of this article
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