When medication response is incomplete, use MRI findings to decide whether the patient is a credible decompression candidate rather than continuing endless empirical drug escalation.

Baclofen, gabapentin, pregabalin, and lamotrigine can help when carbamazepine is not enough; High-resolution MRI is central to confirming neurovascular compression; Root distortion at the brainstem entry zone is highly specific for classical trigeminal neuralgia; Root atrophy or flattening predicts better decompression outcomes; Trigeminal reflex testing is useful when MRI is unavailable or equivocal