Trigeminal Neuralgia Treatment

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. Clusters of attacks can last for several hours.  The pain occurs in areas of the face where the trigeminal nerve supplies normal sensation: cheek, nose, jaw, teeth, gums and lips, and the eye and forehead. This condition causes sudden, sharp and very severe pain, usually only on one side of the face. The pain is described by patients as feeling like stabbing, electric shocks, burning, crushing, exploding or shooting pain. People with this condition may initially experience short, mild attacks, but trigeminal neuralgia can progress, causing longer, more frequent bouts of pain. When severe repeated attacks of pain occur, those affected often have to stop what they are doing, sit down and usually cannot talk to others until the symptoms stop. If left untreated, the condition tends to worsen over time and require increasing doses of medications,  although some patients can undergo spontaneous remission of symptoms over time.  Trigeminal neuralgia  affects women more often than men, and is more likely to occur in people over age 50.

Classic trigeminal neuralgia, or type 1 trigeminal neuralgia, has a number of clinical features.  These include repeated sudden severe episodic pain attacks, which are in the distribution of the trigeminal nerve, restricted to one side of the face. These episodes usually have a trigger zone, or something which provokes the attack such as face washing, chewing, brushing teeth, a cold wind on the face, shaving, or eating.  However, in many patients, the pain is generated spontaneously without any apparent stimulation.  Most patients at the onset of symptoms, are pain free between the sudden attacks, and do not have permanent numbness in the face. Classic trigeminal neuralgia also is initially relieved either partially or completely, by certain anticonvulsant medications. These medications include phenytoin, carbamazepine, oxcarbazepine, gabapentin, and others.  As the condition gets worse, patients can get a component of constant pain that persists in between the severe episodic pain attacks.  If this constant aching or burning pain occurs as the most prominent feature patients are often given a diagnosis of atypical facial pain, or type 2 trigeminal neuralgia.

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Trigeminal neuralgia causes include blood vessels pressing on the trigeminal nerve, which is the most common cause of trigeminal neuralgia, however in some cases the cause is unknown. The most common blood vessel to cause compression of the trigeminal nerve and trigeminal neuralgia is the superior cerebellar artery or a branch of this artery.  On occasion one or more large veins can irritate or compress the nerve and cause the condition.  These vessels can compress or irritate the nerve due to their pulsations or pressure changes between where the nerve exits the brainstem and where in enters the base of the skull.  In rare instances tumors along the pathway of the trigeminal nerve at this or other locations may be responsible for trigeminal neuralgia.  In some cases trigeminal neuralgia can be associated with multiple sclerosis.

Because the condition may be confused with other craniofacial pain syndromes, it is important that patients seek the opinion of a trigeminal neuralgia specialist to help make the diagnosis.  Trigeminal neuralgia specialists are usually neurologists or neurosurgeons, otolarygologists or craniofacial pain specialists.  Other conditions may mimic trigeminal neuralgia including temporomandibular joint pain or jaw pain, sinus infections or other sinus conditions, dental conditions including cavities, infections needing root canals, hypersensitive teeth, and other dental pathology.  Occasionally patients have undergone root canals,  tooth extractions, or other dental procedures in attempts to treat trigeminal neuralgia symptoms, which in retrospect had arisen from the trigeminal nerve itself.

In addition to the clinical symptom description, imaging studies are also utilized, most commonly high resolution MRI of the brain with and without intravenous contrast, and occasionally head CT.  Even though a vascular compression is the most common cause, it is important to rule out tumor, multiple sclerosis, skull base lesions, infections, sinus pathology, temporomandibular joint, and jaw pathology. The finding of vascular compression of the trigeminal nerve on MRI is not 100% reliable in determining of the cause of symptoms for several reasons.  The current MRI scans in use are not of sufficient  resolution to determine if the nerve is compressed or just lying next to a blood vessel. It also may be difficult to determine if an adjacent blood vessel to the trigeminal nerve is an artery or a vein, and whether or not it is causing irritation and hyperexcitability of the nerve, which is usually the cause of the symptoms.

Trigeminal neuralgia treatment options include medical management using carbamazepine, oxcarbazepine, gabapentin, phenytoin, lioresal and others. If patients experience incomplete relief of symptoms, side effects, or toxicity from medications, then other treatments including trigeminal neuralgia surgery, or radiosurgery for trigeminal neuralgia can be effective.  Trigeminal neuralgia surgery most commonly involves microvascular decompression of the trigeminal nerve which is an operative procedure to protect the nerve from irritation by a surrounding blood vessel. Other trigeminal surgery options involve neurolysis, which is partial damage to the nerve by injection of alcohol, balloon compression, or heating/burning with radiofrequency by passing a probe through the cheek into the trigeminal nerve.

 

long term outcome of microvascular decompression