Trigeminal neuralgia or tic douloureux is a chronic pain condition that affects the trigeminal
nerve in the face. The nerve carries sensations from face to the brain. The condition initially
causes a jolt of excruciating pain that is intermittent, short and mild but can progress and cause
longer, more-frequent bouts of searing pain.
Triggering factors of Trigeminal Neuralgia
Mild stimulation of face by any of the following can trigger the pain of trigeminal neuralgia:
- Brushing teeth
- Touching or washing face
- Putting on makeup
Causes of Trigeminal Neuralgia
Trigeminal Neuralgia is caused by a disruption in the functioning of the trigeminal nerve. In
most of the cases it occurs when a normal blood vessel (artery or vein) presses against the
trigeminal nerve at the base of the brain. This pressure on the trigeminal nerve causes it to
Other than this, following may also cause trigeminal neuralgia:
- Aging as it is more likely to occur in people who are older than 50
- Multiple sclerosis or similar disorders that damage the myelin sheath protecting
- Brain lesions or other abnormalities
- Tumor compressing the trigeminal nerve
- Surgical injuries
- Facial trauma
- Sometimes the cause remains unknown
Symptoms of Trigeminal Neuralgia
The symptoms of trigeminal neuralgia may include one or more of the following patterns:
- Sudden, severe & stabbing facial pain that may last from a few seconds to several
- Pain may feel like an electric shock in areas supplied by the trigeminal nerve
including around the cheek, jaw, teeth, gums, lips, or less often the eye and forehead
- Usually the pain is localized to one side of the jaw or cheek but in some cases, it
may occur at different places and at different times
- Frequency of attacks may vary from 1 or 2 per day to almost 12 per hour reaching
up to hundred times per day
- Constant aching, burning feeling that’s less intense than the spasm-like pain
Diagnosis of Trigeminal Neuralgia
There are no specific tests to accurately determine the certainty of the condition and can mainly
be diagnosed based on the description of symptoms specified by the patient including type,
location and trigger of pain. Apart from this, following examinations and diagnostic tests may
help the physician to diagnose the condition:
- A thorough physical and neurological examination
- MRI scans in cases where trigeminal nerve is irritated due to tumor or multiple
sclerosis, can be used to diagnose trigeminal neuralgia
• Anticonvulsant drugs. Carbamazepine is
one of the first choice for treating pain associated with Trigeminal Neuralgia.
Our healthcare provider may also prescribe other Anticonsultant drugs including
Oxcarbazepine, phenytoin, Lamotrigine, sodium valproate, gabapentin, clonazepam
&topiramate and many more. If you have been taking one of these medications
and feel that it isn’t helping as it should, you can ask your doctor to
increase specific dose or you can try another form of medication. While these
anticonvulsant drugs can help relieve pain, the side effects may be including
dizziness, nausea, confusion and drowsiness.
• Tricyclic antidepressants. Amitriptyline
or Nortriptyline are the common medications in this category, and they are
generally used to treat Type 2 trigeminal neuralgia symptoms.
• Muscle relaxants. Baclofen can be used
alone/together with the carbamazepine or phenytoin.
• Other medications. A Botulinum toxin
injection is used to block sensory nerves. In some instances, nerves block is
used to provide temporary relief.
If you don’t have response to any of these
medications or believe your condition is worsening over time, you could be a
candidate for surgery. You have a several surgery options. Specific doctor may
likely recommend one for you based on the severity of pain, your preference,
your physical health, previous surgeries and the surgery related risks and
benefits. Additionally, it is more difficult to perform surgery on those
suffering from Type 2 trigeminal neuralgia.
Percutaneous (through the skin) surgical
• Balloon compression. The surgeon will
insert a tube, called a cannula, through your cheekup to the trigeminal nerve.
From these, they insert a catheter with a small balloon through the tube. They
inflate the balloon, compressing the nerve and damaging the pain-causing
fibers. Balloon and catheter are removed at the end of the procedure. This
procedure has been known to relieve symptoms for 1-2 years, though it can cause
some numbness in the face.
• Glycerol injection rhizotomy. The surgeon
will inject glycerol through a needle into the nerve center, right where it
splits into 3 branches. By injecting these glycerol into the root of the
trigeminal nerve, it causes selective nerve damage that disrupts the body’s
ability to transmit pain signals to the brain. This procedure can suppress pain
for 1-2 years, though it can be performed multiple times. Such procedure can
also cause some facial numbness, as well as tingling.
• Radiofrequency thermal lesioning. The
surgeon will insert a needle through your cheek, all these way through to the
base of your skull, which is then used to send an electrical current to
identify the specific pain point on the trigeminal nerve. The heat is applied
to the nerve until a lesion forms, destroying some of the nerve fibers. About
half of patients WHO options for this procedure see their symptoms return after
3 to 4years. You may also feel facial numbness as a result of this procedure.
Microvascular decompression is a more invasive
surgical procedure. It is typically the
most successful of all these procedures, as it can provide pain relief for up
to 10 years. The goal of this procedure is to provide a long term solution,
where the trigeminal nerve can recover and return to a more normal, pain-free
state. However, it is invasive because the surgeon must create an opening
behind the ear, thus exposing the trigeminal nerve root. This opening reveals
the blood vessel that may be compressing the nerve; once your surgeon identifies
the specific blood vessel, a cushion is placed between the nerve and the blood
vessel. Newer patients who are otherwise in good health are suitable candidates
for this procedure.
If a surgeon attempts to perform
microvascular decompression but doesn’t find a blood vessel actively pressing
against the nerve, neurectomy might be
performed. In this procedure, surgeon cuts either part of the nerve near the
brain stem or some of the nerve’s branches in the face. The neurectomy can have
lasting side effects, including numbness in the areas where the surgeon cuts
part of the nerve & impaired hearing. Nerves in the face, however, can grow
back over time, meaning the pain will return in that specific area as well.
Stereotactic radiosurgery uses Gamma Knife,
Cyber-Knife or LINAC surgery to deliver a highly concentrated amount of
radiation on the trigeminal nerve root, where it meets the brain stem. After
this procedure, a lesion will form on the nerve that will disrupt its ability
to transmit pain signals to the brain, though you may increasingly feel
numbness in your face as a result. It can be a few weeks before you begin to
see the effects of this procedure. Stereotactic radiosurgery generally
eliminates symptoms for about 3 years.
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