Trigeminal Neuralgia (TN) is also known as tic douloureux. This has been sometimes described as the “most excruciating pain known to humanity”. The hallmark of TN is severe pain of the face. The pain comes from the branches of the trigeminal nerve which control facial sensation and is usually described intense and stabbing. The branches are the Ophthalmic V1 from the forehead and upper eyelid to the tip of the nose; Maxillary V2 from the cheek to the bottom of the nose and upper lip; and the Mandibular V3 from the temples in front of the ear to the upper lip and jaw. It usually is limited to one side of the face. Something that would normally cause a mild feeling on your face can become a painful attack. Anticonvulsive medications and surgery are options to treat the debilitating pain.
TN pain may be triggered by facial trauma, dental work, or may just appear one day out of nowhere. The pain is most often located in the lower jaw and it is not uncommon for patients to have had dental procedures for the pain that did not decrease the pain. Pain can be sporadic or constant and there can be long periods up to years both with and without pain. TN attacks will generally intensify over time and the severe pain can cause facial twitching giving it the name Tic Douloureux.
Facial pain is usually on only one side of the face. Multiple sclerosis can cause pain on both sides of the face. TN attacks are triggered by normal sensations that cause pain through the irritated nerve. These include brushing teeth, shaving, washing the face, touching skin, drinking, smiling, talking or feeling a light breeze on the face.
The precise cause of TN is unknown, but the pain is associated with irritation of the nerve. TN can be primary and secondary. Primary trigeminal neuralgia is associated with trigeminal nerve compression especially in the skull base where an artery or vein presses against the trigeminal nerve. Secondary TN is caused by pressure on the nerve from damage to the outer nerve covering from a facial injury, tumor, cyst or multiple sclerosis.
Trigeminal Neuralgia symptoms can be similar to many other facial disorders. The differential diagnosis includes dental pain, cluster headaches, migraines, temporal arteritis, sinus infections, post-herpetic neuralgia and temporomandibular joint syndrome (TMJ). Therefore, TN can be exceedingly difficult to diagnose because there are no specific diagnostic tests and symptoms can overlap with many other facial pain disorders. You should obtain medical care if you are having sharp and unusual facial pain especially if you haven’t had recent dental work.
A physical and neurological exam with a complete history can help diagnose TN. Listening to your symptoms is the most important factor in evaluation especially if there is a history of sudden stabbing pain. Magnetic resonance imaging (MRI) which uses high powered radio waves in a magnetic field to create highly detailed images can detect tumor, trauma, bleeding or multiple sclerosis and may show trigeminal nerve compression by a blood vessel. Testing can also determine or rule out other causes of the pain.
he options to treat Trigeminal Neuralgia include medications and surgery. Patients who do not tolerate medications or do not have adequate symptom relief may require surgery for pain relief. Overall the risks of treatment must be balanced with potential benefits. There is no guarantee that any procedure will help a patient.
Medications, and most commonly anticonvulsants, are used for TN. You are started on a low dosage which is gradually increased depending on your response to the medication. Common anticonvulsant medications include carbamazepine, Gabapentin, Oxcarbazepine which have side effects that include dizziness, drowsiness, nausea and double vision. Additional medications used may include clonazepam, opioids, amitriptyline and valproic acid. Some patients may require high dosage of these medication to control pain and higher doses are associated with greater side-effects. Some of the medications require scheduled blood tests to look for kidney or liver toxicity or bone marrow suppression.
Surgery may help control pain if medications do not work or have too many risks or side-effects. Surgical and procedural techniques include:
Microvascular decompression involves surgically placing a cushion between the vessel and the nerve. A portion of the nerve may also be removed if no arteries or veins are found in contact with the nerve.
Brain stereotactic radiosurgery (Gamma knife) uses highly focused radiation to injure the trigeminal nerve root. This can decrease or eliminate pain but may take a month or more to be effective.
Rhizotomy damages trigeminal nerve fibers and reduces pain but this also causes facial numbness. Types of rhizotomy include Glycerol Injection to inject the nerve, Balloon Compression to compress the nerve, and Radiofrequency Thermal Lesioning to overheat the nerve.
The Norelle Health neurosurgeons are highly trained and skilled in the diagnosis, management, and treatment of Trigeminal Neuralgia. Our neurosurgeons can provide the optimal treatment. Neurosurgery is considered essential by insurances and should be covered with your plan. As out-of-network providers, we will check your benefits for you and let you know what they are so there are no surprises. We use an individualized treatment plan for your concerns to provide a personalized holistic plan of care. If you would like assistance, please feel free to contact us (link to contact page) or call our office (link to phone number).