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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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>We conducted a prospective observational cohort study at a national referral center (2012\u20132019). 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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>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\u20135.50]. Pain-free with medication occurred in 1% after MVD versus 14% of the medical cohort (RR 0.16, 95% CI 0.04\u20130.69). Continued pain on medication was less frequent after MVD (22% vs 49%; RR 0.44, 95% CI 0.24\u20130.80). Male sex predicted excellent outcome after MVD (odds ratio 2.60, 95% CI 1.02\u20136.91). Postoperative hypoesthesia occurred in 23% and hearing impairment in 7%, while 55% of medically treated patients reported side effects.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>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.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1007\/s00415-025-13447-9","type":"journal-article","created":{"date-parts":[[2025,10,16]],"date-time":"2025-10-16T18:41:36Z","timestamp":1760640096000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":7,"title":["Five-year prospective outcomes of medical management and microvascular decompression in trigeminal neuralgia"],"prefix":"10.1007","volume":"272","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-7201-065X","authenticated-orcid":false,"given":"Jacob","family":"Worm","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1318-4262","authenticated-orcid":false,"given":"Tone Bruvik","family":"Heinskou","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Per","family":"Rochat","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0917-3402","authenticated-orcid":false,"given":"Jacob Bertram","family":"Springborg","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0002-8026-4307","authenticated-orcid":false,"given":"Emil Andonov","family":"Smilkov","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4810-4998","authenticated-orcid":false,"given":"Lars","family":"Bendtsen","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6262-2986","authenticated-orcid":false,"given":"Henrik Winther","family":"Schytz","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3309-6120","authenticated-orcid":false,"given":"Stine","family":"Maarbjerg","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2025,10,16]]},"reference":[{"key":"13447_CR1","first-page":"1","volume":"38","author":"J Olesen","year":"2018","unstructured":"Olesen J (2018) Headache Classification Committee of the International Headache Society (IHS) The International Classification of Headache Disorders, 3rd edition. 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