Trigeminal Neuralgia

Trigeminal neuralgia, also called tic doloureux, is a condition characterized by episodes of intense facial pain that lasts from a few seconds to several minutes or hours. The pain occurs in areas of the face where the trigeminal nerve supplies normal sensation: cheek, jaw, teeth, gums and lips, and sometimes the eye or forehead. This condition causes sudden, sharp and very severe pain, usually only on one side of the face. The pain is described as feeling like stabbing electric shocks, burning, crushing, exploding or shooting pain.

Although tumors or blood vessels pressing on the nerve can cause trigeminal neuralgia, in some cases the cause is unknown. In some cases trigeminal neuralgia can be associated with multiple sclerosis.  Patients describe areas on the face as being so sensitive that lightly touching the face or even air currents can trigger an episode of pain. However, in many patients, the pain is generated spontaneously without any apparent stimulation.

People with this condition may initially experience short, mild attacks, but trigeminal neuralgia can progress, causing longer, more frequent bouts of searing pain. If left untreated, the condition tends to worsen over time. It affects women more often than men, and is more likely to occur in people over age 50.

Symptoms

  • Intermittent severe episodic pain on one side of the face or teeth
  • Symptoms may involve the eye, mid face or the lower face, or all regions at once
  • Usually there are pain free intervals in between the attacks of severe pain
  • Sometimes the symptoms are triggered by chewing or touching the face or even wind on the face
  • There is usually normal sensation on the face

Causes

Trigeminal neuralgia in some cases doesn’t have a specific cause. The most common known causes are conditions that can irritate the trigeminal nerve

  • A blood vessel pressing on the trigeminal nerve is the most common cause
  • Tumor (rare)
  • Multiple sclerosis
  • Unknown

Risk Factors

Trigeminal is more common in middle-aged and elderly women. The mean age of onset is approximately 40 years old.

Diagnosis

Your doctor will ask about your symptoms and medical history. A physical exam will be done. Tests may include:

  • An MRI of the brain
  • Evaluations of the teeth or temporo-mandibular joint

Prevention

There are no current guidelines to prevent trigeminal neuralgia.

Treatment

Because of the variety of treatment options available, doctors usually can effectively manage trigeminal neuralgia with medications, injections or surgery. Treatment usually starts with medication. However, over time, some patients eventually stop responding to medications, or may experience unpleasant side effects. For those people, injections or surgery provide other treatment options. Other treatment options for trigeminal neuralgia include alcohol injection, glycerol injection, balloon compression of the trigeminal nerve, radiofrequency thermal rhizotomy, and surgical rhizotomy, which means partially damaging the nerve.

Medication

Medications are used to lessen or block the pain signals sent to your brain, and are the most common initial treatment for trigeminal neuralgia. Some medications include anticonvulsants or antispasmodic agents. These include Carbamazepine, Phenytoin, Gabapentin, Oxcarbamazepine.

Microvascular Decompression Surgery

Microvascular decompression is a delicate procedure that is performed through a small opening behind the ear. The goal of this procedure is to prevent a blood vessel from compressing the trigeminal nerve. The surgery is performed under general anesthesia.

Through this small opening, the neurosurgeon uses a powerful microscope to view the trigeminal nerve. From here, the surgeon meticulously separates the nerve from the artery that is pressing against it. To relieve the pressure, the surgeon inserts a Teflon® pad between the artery and the nerve, keeping the artery from touching the trigeminal nerve.

To make sure that other nerves are not damaged by the surgery, the surgeon carefully monitors nerve function of the facial and acoustic (hearing) nerves. This is done by gently inserting tiny electrodes (metal wires that conduct mild electrical signals) into the muscles around the eye and mouth.

After the Procedure

Following the decompression procedure, the neurosurgeon closes the bony opening behind the ear, and you will be awakened and allowed to recover from anesthesia. Once this pressure has been relieved, patients often report immediate and complete relief from the pain. Most people stay in the hospital for observation overnight. Pain relief is usually immediate and medications are gradually discontinued over a two- week period following surgery.

 

Radiosurgery

Another treatment option for trigeminal neuralgia is radiosurgery. Gamma Knife radiosurgery involves delivering a focused, high dose of radiation to the root of the trigeminal nerve. This treatment uses radiation to damage the trigeminal nerve and reduce or eliminate pain. Relief occurs gradually and can take several weeks to begin.

There are certain reasons why Gamma Knife may be a good treatment option to consider.

  1. There are medications that are used to control trigeminal neuralgia. Each of the drugs, however, has side effects that may be difficult to live with. If you experience side effects to medications or have used these medications and can no longer cope with the side effects, Gamma Knife may be an alternative treatment.
  2. Gamma Knife radiosurgery allows the patient to avoid general anesthesia, an incision in the scalp, and the risk of infection or other surgical complications. Radiosurgery also eliminates the need to shave the head in preparation for surgery, and recovery time is much shorter than the post-surgical hospital stay. Radiosurgery patients usually leave the Radiosurgery Center shortly after treatment and resume their normal daily activities.
  3. While some treatment options are safest for healthy, younger patients, Gamma Knife can be used to treat patients of any age, including the elderly, and to treat patients who may have other chronic medical conditions. Unlike surgery, there is no need to stop anti-coagulation (blood-thinning) medication prior to treatment.

The Gamma Knife procedure has several steps that occur on one day, including imaging, treatment planning and treatment. The treatment itself takes about one hour.

A unique treatment plan is created for each patient based on images that are taken just before treatment. The plan is used to program the Gamma Knife to send hundreds of beams of radiation from multiple angles and directions at the same time to the precise place where the trigeminal nerve exits the brain. This area is called the nerve root. It is the location of the cause of trigeminal neuralgia.

Alone each of those beams of radiation is not strong enough to damage normal brain through which it travels on its way to the target. Where the beams meet, however, the combined strength is enough to destroy the abnormal cells that case the pain of trigeminal neuralgia.

Once you have been diagnosed with trigeminal neuralgia, you and your doctor will discuss all of your treatment options. In planning your treatment, your doctor will consider your particular situation before making a recommendation.

 

Video

David Newell, M.D. talks about trigeminal neuralgia, who it affects, and how it’s treated.

Video demonstration of microvascular decompression of the right trigeminal nerve for trigeminal neuralgia. Surgery performed by David W Newell MD.

Warning: this video contains graphic depictions of neurosurgery.

For an appointment about pain, symptoms, risks, and treatment contact us or to learn more about your world renown surgeons at Seattle Neuroscience Institute visit our home page.