Trigeminal Neuralgia

Symptoms

The main symptom of trigeminal neuralgia is a sudden attack of pain (often described as intense, shooting, stabbing or electrical shock-like) that lasts anywhere from seconds to two minutes. Sometimes the pain hits without warning, while other times even mild stimulation of the face from ordinary activities (such as smiling, brushing teeth, eating, drinking, applying makeup, combing or brushing hair, shaving or touching the skin) can trigger a pain attack. At first the attacks may be short and relatively mild, but over time they last longer, are more painful and happen more often.

The trigeminal nerve has three branches in the face, each of which controls a different part of the face, and any or all branches of the nerve may be affected. The pain typically involves only one side of the face. It can affect the upper, middle or lower portions of the face or all of them. The pain never crosses over to the other side of the face. In rare cases, trigeminal neuralgia is felt on both sides of the face, but the right side pain is separate and distinct from the left side pain.

When experiencing an attack of trigeminal neuralgia, individuals will almost always want to be still and avoid talking or moving the face. The pain may cause the face to contort into a painful wince. Attacks of trigeminal neuralgia rarely occur while sleeping.

During certain periods, the attacks of pain may be worse or more frequent. Individuals may also have extended times with no pain (remission). One of the challenges of trigeminal neuralgia is the inability to predict when the next flare-up may happen. Especially severe flare-ups may produce so many pain attacks that the pain feels nearly constant. In severe or long-term cases of trigeminal neuralgia, an aching pain or light numbness may develop in the affected area of the face.

Causes and Risk Factors

The pain of trigeminal neuralgia is usually caused by pressure on the trigeminal nerve at the base of the brain. The pressure can be result from:

• A stroke that affects the lower part of the brain, where the trigeminal nerve enters
• A tumor that pushes on the nerve
• Contact between a normal artery or vein and the trigeminal nerve (the most common cause of trigeminal neuralgia)
• Injury to the nerve (such as from a car accident or head trauma)
• Surgery on the teeth and gums or the sinuses can also cause injury to the trigeminal nerve
• Multiple sclerosis, which causes damage to the nerves and can affect the trigeminal nerve

This condition occurs most often after the age of 50, although it has been found in children and infants. Women are nearly twice as likely to develop trigeminal neuralgia as men are.

Diagnosis

Trigeminal neuralgia is not easy to diagnose. Neurologic tests and physical examination of the skull and face usually reveal no abnormality. A person experiencing unexplained facial pain may be mistakenly diagnosed as having a dental condition, disorders of the hinge of the jaw (temporomandibular joint), sinus infections, eye conditions, migraines, temporal arteritis or even psychologic disorders. Any doctor or dentist who sees patients with facial, gum or jaw pain should be alert to the possibility that the condition is trigeminal neuralgia.

Usually a diagnosis is based on the description of the pain and related features. The doctor must also eliminate the possibility of other conditions that also may cause facial pain. If the pain is relieved by treatment for trigeminal neuralgia, the diagnosis of the condition is usually confirmed. No known clinical or laboratory tests or X-rays can confirm trigeminal neuralgia. It may be necessary to order an MRI which, in some cases, can help identify the vessel pressing on the nerve.

Treatment

The first treatment for trigeminal neuralgia is usually drug therapy. Certain medications can help lessen or block pain. Additionally, drugs that are designed to control convulsions or seizures or some anti-depressant drugs can be helpful in relieving pain. Drugs that may be prescribed include:

• Baclofen (Lioresal)
• Carbamazepine (Tegretol or Carbatrol)
• Clonazepam
• Gabapentin
• Oxcarbazepine (Trileptal)
• Phenytoin (Dilantin or Phenytek)
• Pregabalin (Lyrica)
• Topiramate (Topamax)
• Valproic acid

If drugs fail to control the pain or if they produce undesirable side effects, neurosurgery may be needed. A variety of surgical techniques are available to treat trigeminal neuralgia. The goal of many of these procedures is to damage or destroy part of the trigeminal nerve that is causing the pain. This can lead to numbness in the face to a varying degree. Some of the surgical options are:

• Injecting alcohol or glycerol near different portions of the trigeminal nerve to either numb it or damage the nerve and block the pain signals that it has been sending
• Injecting a tiny balloon through a thin, flexible tube (a catheter) until it reaches the trigeminal nerve. Once there, the balloon is inflated with enough pressure to damage the nerve and block pain signals.
• Sending an electric current into the root of the trigeminal nerve to damage nerve fibers and help control pain. This procedure is called percutaneous stereotactic radiofrequency thermal rhizotomy (PSRTR).
• Microvascular decompression (MVD), which relocates or removes blood vessels that are in contact with the trigeminal nerve and separates the nerve and the blood vessels with a small pad. Doctors at the Maxine Dunitz Neurosurgical Institute's Trigeminal Neuralgia Program perform this surgery endoscopically, which does not damage the nerve and is less likely to cause side effects (such as numbness).
• Severing the nerve in a procedure called partial sensory rhizotomy (PSR). While this process is helpful, it almost always causes numbness in the face.
• Radiosurgery to damage the nerve and reduce or eliminate the pain. This technique involves sending a focused, intense dose of radiation to the root of the trigeminal nerve. Relief may take several weeks to begin. The procedure is painless and is usually done without anesthesia.

At Cedars-Sinai, treatment of trigeminal neuralgia uses a multidisciplinary approach that brings together neurosurgeons, specialists in pain management, psychologists, a social worker and pharmacologists to devise a customized approach to treating trigeminal neuralgia. Each of these specialists collaborates closely to provide the most appropriate care.

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