Trigeminal Neuralgia
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Trigeminal neuralgia is a condition characterized by intense pain originating from the trigeminal nerve, a nerve that branches near the top of the ear and extends towards the eye, cheek, and jaw. While we have two trigeminal nerves—one for each side of the face—trigeminal neuralgia typically affects only one side.
The pain associated with trigeminal neuralgia is distinct and extremely severe, setting it apart from other facial pains. Described as stabbing, sharp, or electric, the pain reaches such intensity that individuals affected may find it challenging to eat or drink. The pain swiftly travels across the face within seconds, and as the condition progresses, these episodes can extend to minutes and beyond.
Types
Causes
Symptoms
Diagnosis
Complications
Types
Trigeminal Neuralgia manifests in two main types:
1. Type 1 (Classic or Typical):
– Characteristics: This is the typical or “classic” form of the disorder, marked by extreme, intermittent, sudden burning, or shock-like facial pain.
– Duration: Pain episodes last from a few seconds to two minutes. Attacks can occur closely together, and the stretches between attacks may last up to two hours.
– Triggers: Intense flashes of pain can be triggered by various activities such as vibration, contact with the cheek (shaving, washing the face, applying makeup), brushing teeth, eating, drinking, talking, or exposure to the wind.
– Spread: The pain may affect a small area or spread across the face. Attacks rarely occur during sleep.
– Impact: Due to the pain’s intensity, individuals may avoid daily activities or social contacts due to fear of an impending attack.
2. Type 2 (Atypical):
– Characteristics: This is an “atypical” form of the disorder, characterized by constant aching, burning, or stabbing pain, usually of less severity than in Type 1.
– Possibility of Both: It’s possible for an individual to experience both forms of trigeminal neuralgia simultaneously.
– Intensity: While the pain is less severe than in Type 1, it can still be physically and mentally debilitating.
In both types, trigeminal neuralgia attacks may cease for a period but often return. In some cases, the condition can be progressive, leading to worsening attacks over time, with fewer and shorter pain-free intervals before recurrence. In progressive cases, the pain-free periods eventually disappear, and medications become less effective in controlling the pain.
Causes
Trigeminal neuralgia can be caused by various factors, including:
1. Nerve Compression from a Tumor:
– Mechanism: Compression of the trigeminal nerve can occur due to the presence of a tumor.
– Effect: This compression can lead to the development of trigeminal neuralgia.
2. Arteriovenous Malformation (AVM):
– Mechanism: An abnormal tangle of arteries and veins, known as an arteriovenous malformation (AVM), can contribute to trigeminal neuralgia.
– Effect: The presence of an AVM can exert pressure on the trigeminal nerve, leading to neuralgia symptoms.
3. Injury to the Trigeminal Nerve:
– Causes: Trigeminal neuralgia may result from injury to the trigeminal nerve, which can occur due to various factors such as sinus surgery, oral surgery, stroke, or facial trauma.
– Effect:Damage to the trigeminal nerve can lead to the onset of neuralgia symptoms.
Understanding the underlying causes is crucial in determining the appropriate treatment approach for individuals experiencing trigeminal neuralgia.
Symptoms
The symptoms of neuralgia, specifically trigeminal neuralgia, include:
1. Sudden, intense pain: The hallmark symptom is the onset of sudden and intense pain, typically affecting one side of the face.
2. Duration of pain attacks: Pain attacks can be brief, lasting for a few seconds. In some cases, attacks can extend up to about two minutes.
3. Numbness or tingling sensation: Individuals may experience numbness or a tingling sensation in the affected area.
4. Varied sensations: The pain may manifest as burning, throbbing, shock-like, or aching sensations. The quality of pain can vary among individuals.
5. Regular and recurrent attacks: Pain attacks may occur regularly for days, weeks, or even longer durations. In some cases, individuals may experience several episodes of pain throughout the day.
Trigeminal neuralgia is characterized by the sudden and severe nature of the pain attacks, and the symptoms can significantly impact an individual’s quality of life. The exact presentation of symptoms may vary among individuals, and effective management often involves a personalized approach based on the specific characteristics of the condition in each case.
Diagnosis
The diagnosis of trigeminal neuralgia (TN) primarily relies on your medical history and the description of symptoms, coupled with the findings from physical and neurological examinations.
Before confirming a TN diagnosis, other disorders causing facial pain must be ruled out. Some of these include:
1. Post-herpetic neuralgia (nerve pain following a shingles outbreak).
2. Cluster headaches.
3. Temporomandibular joint disorder (TMJ), which induces pain and dysfunction in the jaw joint and associated muscles.
To further investigate the cause of pain, you might be advised to undergo a magnetic resonance imaging (MRI) brain scan. This helps rule out conditions like tumors or multiple sclerosis. While this scan may not always clearly reveal a blood vessel compressing the nerve, specialized MRI imaging procedures can provide more insight into the presence and severity of such compression.
For suspected TN1 cases, doctors might suggest a short course of antiseizure medication. A positive response to this medication can contribute to supporting a diagnosis of TN1.
Diagnosing TN2 is more intricate. Doctors may ask you to try low doses of a tricyclic antidepressant medication (such as amitriptyline and nortriptyline) to assess its efficacy. If there is a positive response to this treatment, it can aid in confirming a diagnosis of TN2.
Complications
Complications of untreated trigeminal neuralgia may include double vision, jaw weakness, loss of corneal reflex, dysesthesia (troublesome numbness), and very rarely, anesthesia dolorosa. Partial facial numbness in the area where the pain existed is expected. Additionally, other complications like blurred vision or chewing problems are usually temporary. Seeking prompt medical attention is crucial to prevent the progression of these complications and improve the management of symptoms.
Treatment of Trigeminal Neuralgia
There are several effective ways to alleviate the pain, including a variety of medications. Medications are generally started at low doses and increased gradually based on patient’s response to the drug.
There are drawbacks to medications. 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 bone marrow suppression and kidney and liver toxicity. These patients must have their blood monitored to ensure their safety.
If medications have proven ineffective in treating TN, several surgical procedures may help control the pain.
Surgical treatment is divided into two categories: 1) open cranial surgery or 2) lesioning procedures. In general, open surgery is performed for patients found to have pressure on the trigeminal nerve from a nearby blood vessel, which can be diagnosed with imaging of the brain, such as a special MRI. This surgery is thought to take away the underlying problem causing the TN. In contrast, lesioning procedures include interventions that injure the trigeminal nerve on purpose, in order to prevent the nerve from delivering pain to the face. The effects of lesioning may be shorter lasting and may result in numbness to the face.
Surgery
Stereotactic radiosurgery
Neuromodulation
Surgery
Surgical treatment is divided into two categories: 1) open cranial surgery or 2) lesioning procedures. In general, open surgery is performed for patients found to have pressure on the trigeminal nerve from a nearby blood vessel, which can be diagnosed with imaging of the brain, such as a special MRI. This surgery is thought to take away the underlying problem causing the TN. In contrast, lesioning procedures include interventions that injure the trigeminal nerve on purpose, in order to prevent the nerve from delivering pain to the face. The effects of lesioning may be shorter lasting and may result in numbness to the face.
- Open Surgery
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 decreased hearing, facial weakness, facial numbness, double vision, stroke or death. - Lesioning Procedures
Percutaneous radiofrequency rhizotomy treats TN 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 fibers. - Percutaneous balloon compression utilizes 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 fibers produce pain. The balloon compresses the nerve, injuring the pain-causing fibers, and is then removed.
- Percutaneous glycerol rhizotomy utilizes glycerol injected through a needle into the area where the nerve divides into three main branches. The goal is to damage the nerve selectively in order to interfere with the transmission of the pain signals to the brain.
Stereotactic radiosurgery
Stereotactic radiosurgery (through such procedures as Gamma Knife, Cyberknife, Linear Accelerator (LINAC) delivers a single highly concentrated dose of ionizing radiation to a small, precise target at the trigeminal nerve root. This treatment is noninvasive and 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 transmission of pain signals to the brai
Neuromodulation
For patients with neuralgia, another surgical procedure can be done 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 deeper into the brain, to deliver electrical stimulation to the part of the brain responsible for 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.
