Who Gets Trigeminal Neuralgia?
What Are the Symptoms of Trigeminal Neuralgia?
How Does Trigeminal Neuralgia Occur?
The Diagnosis and Treatment of Trigeminal Neuralgia
Trigeminal Neuralgia Websites
More Information on Pain Treatment
Trigeminal neuralgia is among the most common facial pain syndromes
and has also been called tic doloreaux. While
it may be caused by compressive blood vessels, tumors and vascular malformations,
its basic pathophysiology (or pain mechanism) remains unknown. What
is known is the sudden, stabbing, excruciating pain that it produces,
which lasts only a few seconds and affects the face.
Trigeminal neuralgia is typically diagnosed in adults. Women are affected
more than men at a rate of 60%, and those suffering from multiple sclerosis
are at increased risk for developing it (although the vast majority
of sufferers do not have multiple sclerosis).
The primary symptom of trigeminal neuralgia is the sudden onset of
severe, sharp facial pain, usually without warning. The quick bursts
of pain are described as "lightning bolt-like" or "machine
gun-like." It can build in strength, decrease and begin again,
and then abruptly end. It can be triggered by stimuli as light as a
breeze or a touch on the face, or by such acts as shaving, teeth brushing,
talking, chewing and swallowing. It also can disrupt sleep, awakening
people from deep slumber. As a result, some sufferers may become both
physically and mentally incapacitated from the pain of trigeminal neuralgia.
They may be fearful of eating and avoid activities of self-care. In
addition, when the pain is especially unrelenting and prolonged, they
may become prone to depression and even suicidal tendencies. It is not
uncommon for people to visit their dentist, believing that their jaw
pain is due to a problem with their teeth, and have unnecessary extractions.
During a pain period, attacks can occur hundreds of times a day. The
interval between attacks can range from minutes to months or even years,
and pain is completely absent during these times. Recurrences of the
pain are almost always in the same area of the face, but tend to spread.
The trigeminal nerve is the fifth and largest of the brain's twelve
nerves, carrying both motor and sensory messages from the face to the
brain. The most common cause of trigeminal neuralgia is idiopathic --
that is, unknown. However, the current theory is that disease or irritation
of the nerve increases the firing of sensory impulses, so much so that
trigger points for pain develop on the face and in the mouth as a result
of this overload. Trigeminal neuralgia also can be activated by such
conditions as multiple sclerosis, tumors and abnormal blood vessels.
Stress is less often a contributing factor.
A diagnosis is made by considering the patient's medical history and
description of his or her pain. While no specific diagnostic tests are
available to confirm the presence of trigeminal neuralgia, diagnostic-imaging
technologies, including CT scans and MRIs, are often used to assess
the patient and make sure that a tumor or other abnormality is not causing
the pain. Additionally, a comprehensive medical history is taken and
a thorough physical exam is performed to determine triggering stimuli,
tender zones, and the exact location(s) of the pain. The exam includes
inspection of the corneas, nostrils, gums, tongue and insides of the
cheeks to see how these areas respond to touch and changes in temperature
(heat and cold).
In most cases, treatment for trigeminal neuralgia begins with anticonvulsant
drug therapy that seeks to suppress the transmission of impulses by
the trigeminal nerve. Carbamazepine is the first drug of choice. It
should be started at low doses and titrated, and taken with food or
fluid. Patients may experience gastric irritation, a lower white cell
count and central nervous system side effects, such as dizziness and
walking off balance; fever, sore throat and bruises should be reported
to their physician immediately. While most patients experience some
relief, they may eventually develop a tolerance to carbamazepine and
stop responding after months or years. Other possibly effective anticonvulsant
drugs include phenytoin, gabapentin and lamotrigine. A small number
of patients do not respond well or at all to anticonvulsants and should
be put on a drug called baclofen. Although baclofen has fewer and less
serious side effects than carbamazepine, it too can lose its effectiveness
over time. Additionally, it can cause drowsiness, dizziness and fatigue.
Baclofen may provide enhanced relief when used in combination with an
anticonvulsant. Other less frequently used drugs to treat trigeminal
neuralgia include valproate, corticosteroids and mexiletine. Luckily,
most patients obtain relief with one or a combination of drugs.
Unlike other neuropathic pains, trigeminal neuralgia only responds
to anticonvulsants and does not respond to antidepressants or opioids.
When drug therapy is unsuccessful, invasive procedures are tried. Nerve
blocks using local anesthetics can be injected into the trigger area
or pain site for temporary relief. Glycerol injections, which can be
done under general anesthesia or following intravenous sedation, can
destroy the fibers that conduct triggering impulses, with less sensory
loss. While glycerol injections have a high initial success rate, the
incidence of pain recurrence is great -- after five years. The most
commonly used surgical technique is microvascular decompression, an
inpatient procedure requiring general anesthesia that allows surgeons
to reposition arteries or veins pressing on the trigeminal nerve. Upwards
of 80% of patients experience long-term pain relief and retain normal
sensation in the face with a lower chance of recurrence, although recurrences
Radiofrequency gangliolysis (RFG) involves wounding the gasserian ganglion,
the large, flat root of the trigeminal nerve. Guided by x-ray technology,
the surgeon inserts a needle through the cheek and into the rootlets
behind the gasserian ganglion to inject a radiofrequency current. This
current heats and destroys selected portions of the gasserian ganglion
thought to be responsible for the pain. A percutaneous procedure, RFG
provides relief in almost all patients; however, the recurrence rate
following RFG is 20 to 30%. RFG is used especially to treat debilitated
or elderly patients who would be at risk from major surgery.
In cases where microvascular decompression cannot be tolerated or RFG
has failed, peripheral neurectomy or neurolysis may be performed. This
surgical and chemical destruction of the peripheral branches of the
trigeminal nerve produces dense numbness to alleviate pain. Relief rarely
lasts more than one year, necessitating repeat procedures.
Treatment Guidelines: Trigeminal Neuralgia (National Guideline Clearinghouse)
National Institutes of Health: Medline Plus
Trigeminal Neuralgia Association
eMedicine: Trigeminal Neuralgia
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