Trigeminal Neuralgia

What is Trigeminal Neuralgia?

Trigeminal neuralgia (TN) is a chronic pain condition that affects the trigeminal nerve, which carries sensation from your face to your brain. You might also hear it called “tic douloureux.” There are about 12 cases per 100,000 people in the United States each year. If you have trigeminal neuralgia, even mild stimulation of your face – such as from brushing your teeth or putting on makeup — may trigger a jolt of excruciating pain.

What are the Symptoms?

People who have this condition often describe the pain as feeling like electric shocks or stabbing, and it can sometimes be intense. The pain can be brought on by mild stimulation of the face, such as brushing your teeth or shaving. You may feel as though your pain came out of nowhere. Some people with this condition start out thinking they have an abscessed tooth and go to a dentist. People with TN may initially have short, mild instances of pain, but over time they may experience longer, more frequent attacks of intense pain. Most people with TN experience symptoms in cycles — pain comes and goes for days or weeks, then subsides. In some cases, the condition becomes progressive and pain is always present.

Initially, you may experience short, mild attacks. But trigeminal neuralgia can progress and cause longer, more-frequent bouts of searing pain.

Trigeminal neuralgia symptoms may include one or more of these patterns:

  • Episodes of severe, shooting or jabbing pain that may feel like an electric shock
  • Spontaneous attacks of pain or attacks triggered by routine activities such as:
    • touching the face
    • washing your face
    • chewing
    • shaving
    • putting on makeup
    • speaking
    • brushing your teeth
    • a breeze on your face
  • Bouts of pain lasting from a few seconds to several minutes
  • Episodes of several attacks lasting days, weeks, months or longer — some people have periods when they experience no pain
  • Constant aching, burning feeling that may occur before it evolves into the spasm-like pain of trigeminal neuralgia
  • Pain in areas supplied by the trigeminal nerve, including the cheek, jaw, teeth, gums, lips, or less often the eye and forehead
  • Pain affecting one side of the face at a time, though may rarely affect both sides of the face
  • Pain focused in one spot or spread in a wider pattern
  • Attacks that become more frequent and intense over time
  • Some people with this condition also have anxiety because they are uncertain when the pain will return.

What are the Causes?

In trigeminal neuralgia, the trigeminal nerve’s function is disrupted. Usually, the problem is contact between a normal blood vessel — in this case, an artery or a vein — and the trigeminal nerve at the base of your brain. This contact puts pressure on the nerve and causes it to malfunction.

In many cases, the cause of TN is never found. However, trigeminal neuralgia can be related to certain diseases, such as multiple sclerosis or a similar disorder, can injure the myelin sheath, which protects certain nerves. Trigeminal neuralgia can also be caused by a tumor compressing the trigeminal nerve.

Some people may experience trigeminal neuralgia due to a brain lesion or other abnormalities. Your trigeminal nerve can also be injured – perhaps by surgery, an accident, or a stroke.

What are the Risk Factors?

Trigeminal neuralgia affects women more often than men, and the disease is more common in people older than 50 (but can affect people of any age). The disorder may run in families, perhaps because of how blood vessels are formed in the brain. It may also be linked to high blood pressure.

What are the Treatments?

Trigeminal neuralgia treatment typically begins with medications, and injections and surgical treatments are also available.

Medications

Your doctor will usually prescribe medications to lessen or block the pain signals sent to your brain in order to treat trigeminal neuralgia. These medications can include:

Anticonvulsants. Doctors usually prescribe carbamazepine (Tegretol, Carbatrol, others) for trigeminal neuralgia, and it’s been shown to be effective in treating the condition. Other anticonvulsant drugs that may be used to treat trigeminal neuralgia include oxcarbazepine (Trileptal), lamotrigine (Lamictal) and phenytoin (Dilantin, Phenytek). Other drugs, including clonazepam (Klonopin) and gabapentin (Neurontin, Gralise, others), also may be used.

If the anticonvulsant you’re using begins to lose effectiveness, your doctor may increase the dose or switch to another type. Side effects of anticonvulsants may include dizziness, confusion, drowsiness and nausea. Also, carbamazepine can trigger a serious drug reaction in some people, mainly those of Asian descent, so genetic testing may be recommended before you start carbamazepine.

Antispasmodic agents. Muscle-relaxing agents such as baclofen (Gablofen, Lioresal) may be used alone or in combination with carbamazepine. Side effects may include confusion, nausea and drowsiness.

Botox injections. Small studies have shown that onabotulinumtoxinA (Botox) injections may reduce pain from trigeminal neuralgia in people who are no longer helped by medications. However, more research needs to be done before this treatment is widely used for this condition.

Surgery

Over time, your medication may help you less and less. That’s common among people with trigeminal neuralgia. If that happens, you have several surgical options.

Some surgical procedures are outpatient, meaning they do not require you to be admitted a hospital. Some require general anesthesia, which means you won’t be awake during the surgery.

Your doctor can help you decide which surgery is right for you, based on your overall health, which nerves are involved, and your preferences.

Surgical options for trigeminal neuralgia include:

  1. Microvascular decompression. This procedure involves relocating or removing blood vessels that are in contact with the trigeminal root to stop the nerve from malfunctioning. During microvascular decompression, your doctor makes an incision behind the ear on the side of your pain. Then, through a small hole in your skull, your surgeon moves any arteries that are in contact with the trigeminal nerve away from the nerve, and places a soft cushion between the nerve and the arteries. If a vein is compressing the nerve, your surgeon may remove it. Doctors may also cut part of the trigeminal nerve (neurectomy) during this procedure if arteries aren’t pressing on the nerve.Microvascular decompression can successfully eliminate or reduce pain most of the time, but pain can recur in some people. Microvascular decompression has some risks, including decreased hearing, facial weakness, facial numbness, a stroke or other complications. Most people who have this procedure have no facial numbness afterward.
  2. Brain stereotactic radiosurgery (Gamma knife). In this procedure, a surgeon directs a focused dose of radiation to the root of your trigeminal nerve. This procedure uses radiation to damage the trigeminal nerve and reduce or eliminate pain. Relief occurs gradually and may take up to a month. Brain stereotactic radiosurgery is successful in eliminating pain for the majority of people. If pain recurs, the procedure can be repeated. Facial numbness can be a side effect.

Other procedures may be used to treat trigeminal neuralgia, such as a rhizotomy. In a rhizotomy, your surgeon destroys nerve fibers to reduce pain, and this causes some facial numbness. Types of rhizotomy include:

  • Glycerol injection. During this procedure, your doctor inserts a needle through your face and into an opening in the base of your skull. Your doctor guides the needle into the trigeminal cistern, a small sac of spinal fluid that surrounds the trigeminal nerve ganglion — where the trigeminal nerve divides into three branches — and part of its root. Then, your doctor will inject a small amount of sterile glycerol, which damages the trigeminal nerve and blocks pain signals. This procedure often relieves pain. However, some people have a later recurrence of pain, and many experience facial numbness or tingling.
  • Balloon compression. In balloon compression, your doctor inserts a hollow needle through your face and guides it to a part of your trigeminal nerve that goes through the base of your skull. Then, your doctor threads a thin, flexible tube (catheter) with a balloon on the end through the needle. Your doctor inflates the balloon with enough pressure to damage the trigeminal nerve and block pain signals. Balloon compression successfully controls pain in most people, at least for a period of time. Most people undergoing this procedure experience at least some transient facial numbness.
  • Radiofrequency thermal lesioning. This procedure selectively destroys nerve fibers associated with pain. While you’re sedated, your surgeon inserts a hollow needle through your face and guides it to a part of the trigeminal nerve that goes through an opening at the base of your skull. Once the needle is positioned, your surgeon will briefly wake you from sedation. Your surgeon inserts an electrode through the needle and sends a mild electrical current through the tip of the electrode. You’ll be asked to indicate when and where you feel tingling. When your neurosurgeon locates the part of the nerve involved in your pain, you’re returned to sedation. Then the electrode is heated until it damages the nerve fibers, creating an area of injury (lesion). If your pain isn’t eliminated, your doctor may create additional lesions. Radiofrequency thermal lesioning usually results in some temporary facial numbness after the procedure. Pain may return after three to four years.

Your doctor at Comprehensive Spine & Pain Physicians can provide information on the benefits and risks associated with any form of treatment. Upon evaluating your symptoms, medical history, and personal preference, your doctor will help you decide which treatment option is best for you.

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