Classical trigeminal neuralgia (TN) is a rare neuropathic pain with distinct diagnostic criteria. The aim of this review is to provide recommendations for medical management based on current evidence and provide some pointers on the conduct of future trials. A review of the literature identified four systematic reviews, of which one was a meta-analysis and 18 randomized controlled trials (RCT) on medical management of trigeminal neuralgia. The evidence suggests that carbamazepine is still the first line drug for medical management, but this should be changed to oxcarbazepine if there is poor efficacy and an unacceptable side effect profile. Combination of carbamazepine with lamotrigine or baclofen is the second line treatment when monotherapy fails, but the evidence is weak. An early neurosurgical opinion should be sought when a patient has a neurovascular contact of the trigeminal nerve, poor efficacy and tolerability of drug treatment and no remission periods. Many of the new antiepileptic drugs need to be evaluated in RCTs with innovative designs and robust outcome measures.