Trigeminal neuralgia (TN), sometimes referred to as tic douloureux can be described as the most excruciating pain experienced by a patient.
The pain typically involves the lower face and jaw. However, it can also affect the area around the nose and above the eye. The intense, stabbing, electric shock-like pain is caused by irritation of the trigeminal nerve, which sends branches to the forehead, lower jaw and cheek. The pain is usually limited to one side of the face. The pain can be triggered by an action as routine and minor as eating, brushing your teeth, or even the wind. Attacks may begin short-lived and mild, but if left untreated, trigeminal neuralgia can worsen progressively.
Although trigeminal neuralgia cannot always be permanently cured, treatments can alleviate the debilitating pain. Typically, anticonvulsive medications are the first treatment choice. Surgery can also be an effective option for those who become unresponsive to medications or for those who suffer serious side effects from the medications.
The trigeminal nerve is the nerve responsible for providing sensation to the face and is one set of cranial nerves in the head. One trigeminal nerve runs to either side of the face on the left and right. Each of these nerves has three distinct branches. (The name Trigeminal derives from the Latin word “tria,” meaning “three”, and “geminus,” which means twin). When the trigeminal nerve leaves the brain and travels inside the skull, it divides into three smaller branches, controlling sensations across the face:
V1 – Ophthalmic Nerve: – controls sensation in a person’s eye, upper eyelid, and forehead.
V2 – Maxillary Nerve: – controls sensation in the lower eyelid, cheek, nostril, upper lip, and upper gum.
V3 – Mandibular Nerve: – controls sensations in the jaw, lower lip, lower gum, and some of the muscles used for chewing.
Trigeminal Neuralgia can occur at any age. It is most common in adults over the age of 50 and is twice as common in women than in men. A form of Trigeminal Neuralgia is also associated with multiple sclerosis (MS).
There are two types of trigeminal neuralgia— primary and secondary. The exact cause of Trigeminal neuralgia is still unknown, but the pain associated with it represents a nerve irritation. Primary trigeminal neuralgia has been linked to the compression of the nerve, typically in the base of the head where the brain meets the spinal cord. This is usually due to contact between a healthy artery or vein and the trigeminal nerve at the base of the brain. This places pressure on the nerve as it enters the brain and causes it to misfire. Secondary trigeminal neuralgia is caused by pressure on the nerve from MS, a tumor, a cyst, an injury to the face or another condition that damages the myelin sheaths.
Most patients report that their pain begins spontaneously and seemingly out of nowhere. Other patients say their pain follows a blow to the face or after dental work. In dental cases, it is more likely that the disorder was developing before a dental issue and then caused the initial symptoms to be triggered. Pain often is first experienced along the upper or lower jaw, so many patients assume they have a dental abscess. Some patients see their dentists and actually have a root canal performed, which inevitably brings no relief. When the pain persists, patients realise the problem is not dental-related.
The pain of trigeminal neuralgia is defined as either type 1 (TN1) or type 2 (TN2). TN1 is characterised by a sporadic, intensely sharp, throbbing, burning or shock-like pain around the eyes, lips, jaw, nose, forehead and scalp. TN1 can worsen, resulting in more pain spells that last longer over time. TN2 pain is often a continuous, burning, aching sensation and may also have stabbing pain, typically less intense than TN1.
With trigeminal neuralgia, patients tend to suffer long periods of frequent attacks, followed by weeks, months or even years of little or no pain. The usual pattern, however, is for the attacks to intensify over time with shorter pain-free periods. Some patients suffer less than one attack daily, while others experience more than ten every hour. The pain typically begins with a sensation of electrical shocks that culminates in an excruciating stabbing pain within less than 20 seconds. The pain often leaves patients with uncontrollable facial twitching, which is why the disorder is also known as tic douloureux.
Pain can be focused in one location, or it can spread across the face. Typically, it is only on one side; however, on rare occasions and sometimes when associated with multiple sclerosis (MS), patients may feel pain on both sides of their face. Pain areas include the jaw, teeth, gums, lips, cheeks, eyes and forehead.
The symptoms of several pain disorders are similar to those of trigeminal neuralgia. The most common is trigeminal neuropathic pain (TNP). Which results from an injury or damage to the trigeminal nerve. trigeminal neuropathic pain is generally described as being a constant, dull and burning pain. Attacks of sharp pain can also occur, commonly triggered by touch. Other mimicking pains include:
Trigeminal neuralgia can be very difficult to diagnose because there are no specific diagnostic tests and symptoms are very similar to other facial pain disorders. Therefore, it is essential to seek medical care when feeling an unusual, sharp pain around the eyes, lips, nose, jaw, forehead and scalp, especially if you have not had facial surgery or dental treatment recently. You may address your pain with the family GP in the first instance, and they may refer the patient to a specialist later or directly consult a specialist such as your neurosurgeon.
Magnetic resonance imaging (MRI) can detect if a tumor or MS affects the trigeminal nerve. An MRI can reveal if there is compression caused by a blood vessel. Advanced scanning techniques can show if a vessel is pressing on the nerve and may even show the level of compression. Compression due to veins is not as easily identified on these scans.
Tests can help rule out other causes of facial disorders. Trigeminal neuralgia usually is diagnosed based on the description of the symptoms provided by the patient, detailed patient history and clinical evaluation. There are no specific diagnostic tests for trigeminal neuralgia, so your doctor must rely heavily on symptoms and history. A specialist will base their diagnosis on the type of pain (sudden, quick and shock-like), the location of the pain and the things that trigger it. A physical, neurological examination may also be done in which the doctor will touch and examine parts of your face to better understand the location of the pain.
There are several effective ways to manage the pain, including various medications. Medications are generally started at low doses and increased gradually based on the patient’s response to the drug.
An anticonvulsant drug, is the most common medication used in the early stages of the disease. Carbamazepine controls pain for most people. When a patient shows no relief from this medication, a physician has cause to doubt whether trigeminal neuralgia is present. However, the effectiveness of carbamazepine decreases over time. Possible side effects include dizziness, double vision, drowsiness and nausea.
An anticonvulsant drug, which is most commonly used to treat epilepsy or migraines, can also treat trigeminal neuralgia. Side effects of this drug are minor and include dizziness and/or drowsiness which go away on their own.
Has been used more recently as the first line of treatment. It is structurally related to carbamazepine and may be preferred as it generally has fewer side effects. Possible side effects include dizziness and double vision.
Other medications can also be used. However, there are drawbacks to these medications other than side effects. Some patients may need relatively high doses to alleviate the pain, and the side effects can become more pronounced at higher doses. Anticonvulsant drugs may lose their effectiveness over time. Some patients may need a higher dose to reduce the pain or a second anticonvulsant, which can lead to adverse drug reactions.
Many of these drugs can have a toxic effect on some patients, particularly people with a history of liver and kidney toxicity or bone marrow suppression. In this case, blood monitoring is essential to ensure their safety.
If medications have proven ineffective in treating trigeminal neuralgia, several surgical procedures may help control the pain. Surgical treatments are divided into two categories:
1) open cranial surgery
2) lesioning procedures
In general, open surgery is performed for patients with pressure on the trigeminal nerve from a nearby blood vessel, which can be diagnosed with brain imaging, such as MRI. This surgery is thought to remove the underlying problem causing trigeminal neuralgia. In contrast, lesioning procedures include interventions that injure the trigeminal nerve on purpose to prevent the nerve from delivering pain to the face. The effects of lesioning may be shorter lasting and, in some cases, may result in numbness to the face.
Microvascular decompression involves microsurgical exposure of the trigeminal nerve root, identification of a blood vessel that may be compressing the nerve, and gentle movement of the blood vessel away from the point of compression. Decompression may reduce sensitivity and allow the trigeminal nerve to recover and return to a more normal, pain-free condition. While this generally is the most effective surgery, it also is the most invasive because it requires opening the skull through a craniotomy. There is a small risk of facial weakness, decreased hearing, facial numbness, double vision, stroke or death.
Percutaneous radiofrequency rhizotomy treats trigeminal neuralgia through the use of electrocoagulation (heat). It can relieve nerve pain by destroying the part of the nerve that causes pain and suppressing the pain signal to the brain. The surgeon passes a hollow needle through the cheek into the trigeminal nerve. A heating current, which is passed through an electrode, destroys some of the nerve fibres.
Utilising a needle that is passed through the cheek to the trigeminal nerve. The neurosurgeon places a balloon in the trigeminal nerve through a catheter. The balloon is inflated, where fibres produce pain. The balloon compresses the nerve, injuring the pain-causing fibres, and is then removed.
Utilising glycerol injected through a needle into the area where the nerve divides into three main branches. The goal is to damage the nerve selectively to interfere with the transmission of pain signals to the brain.
(through such procedures as Gamma Knife, Cyberknife, and Linear Accelerator (LINAC) delivers a single highly concentrated dose of ionising radiation to a tiny, precise target at the trigeminal nerve root. This noninvasive treatment avoids many of the risks and complications of open surgery and other treatments. Over a period of time and as a result of radiation exposure, the slow formation of a lesion in the nerve interrupts the transmission of pain signals to the brain.
For patients with trigeminal neuralgia pain, another surgical procedure can be undertaken by a functional neurosurgeon that includes placement of one or more electrodes in the soft tissue near the nerves, under the skull on the covering of the brain and sometimes more profound into the brain, to deliver electrical stimulation to the part of the brain responsible for the sensation of the face. In peripheral nerve stimulation, the leads are placed under the skin on branches of the trigeminal nerve. In motor cortex stimulation (MCS), the area which innervates the face is stimulated. In deep brain stimulation (DBS), regions that affect sensation pathways to the face may be stimulated.
In all cases, the benefits of surgery or lesioning techniques should always be weighed carefully against their risks. Although many trigeminal neuralgia patients report pain relief after procedures, there is no guarantee that they will help every individual.
This information is provided as a guide only, For all medical concerns or diagnosis, please consult a registered specialist. As with any surgical procedure, there are risks involved. A patient’s age, medical condition, and symptoms must be considered before any of the above-mentioned procedures can be considered to determine suitability for treatment.
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