What is Trigeminal Neuralgia?
Trigeminal neuralgia or tic douloureux is a chronic pain condition characterized by severe, often debilitating facial pain. It typically involves the lower face and jaw, although sometimes it affects the area around the nose and above the eye. The pain is described as intense, stabbing, and an electric shock. The pain seldom lasts more than a few seconds or a minute or two per episode.
Causes of Trigeminal Neuralgia include irritation of the trigeminal nerve, which sends branches to the forehead, cheek, and lower jaw. It is usually limited to one side of the face. Burning, constant, or bilateral pain is atypical for trigeminal neuralgia and may suggest the presence of an unrelated facial pain syndrome. The pain of trigeminal neuralgia can be triggered by vibration or contact with the cheek (such as when shaving, washing the face, or applying makeup), brushing teeth, eating, drinking, or talking. Although sometimes debilitating, the disorder is not life-threatening.
Although trigeminal neuralgia cannot always be cured, there are treatments available to help reduce the excruciating pain. Anticonvulsive medications are normally the first treatment choice. Surgery can be an effective option for those who become unresponsive to medications or for those who suffer side effects from the medications.
The Trigeminal Nerve
The trigeminal nerve is the fifth of 12 pairs of cranial nerves in the skull. It is sometimes abbreviated as CN V (cranial nerve five). It is the nerve responsible for providing sensation to the face. After the trigeminal nerve leaves your brain and travels inside your skull, it divides into three smaller branches. The first branch goes to the forehead and area around the eye. The second goes to the check area, and the third to the jaw.
Prevalence and Incidence
Trigeminal neuralgia is relatively rare. The incidence increases with age. Trigeminal neuralgia is more common in women than in men and rarely starts before the sixth decade of life. Multiple sclerosis and high blood pressure are both risk factors.
Causes of Trigeminal Neuralgia
The pain associated with trigeminal neuralgia represents an irritation of the nerve. The cause of the pain usually is due to contact between a normal artery and the trigeminal nerve at the root entry zone. This pressure and the pulsations of the artery cause the nerve to behave in a way that severe pain is felt. More rarely, causes of trigeminal neuralgia are due to a tumor or multiple sclerosis.
Symptoms of Trigeminal Neuralgia
Pain is often first experienced along the upper or lower jaw and many patients assume they have a dental abscess. Some patients see their dentists and actually have a root canal performed, which brings no relief. When the pain persists, patients realize the problem is not dental-related.
Trigeminal neuralgia tends to run in cycles. Patients often suffer long stretches of frequent attacks followed by weeks, months or even years of little or no pain. The usual pattern, however, is for the attacks to intensify over time with shorter pain-free periods. The pain often leaves patients with uncontrollable facial twitching, which is why the disorder is also known as tic douloureux.
Diagnosing Trigeminal Neuralgia
Magnetic resonance imaging (MRI) can detect if a tumor or multiple sclerosis is irritating the trigeminal nerve. However, unless a tumor or multiple sclerosis is the cause, imaging of the brain is usually normal. The vessel touching the nerve root is difficult to see even on a high quality MRI. Tests can help rule out other causes of facial disorders. Trigeminal neuralgia is usually diagnosed based on the description of the symptoms provided by the patient.
Treatments for Trigeminal Neuralgia
Today, there are several effective ways to alleviate the pain, including a variety of medications. Carbamezepine is the most common medication used to treat trigeminal neuralgia. This medication is commonly used for seizures but can often be effective in reducing pain from trigeminal neuralgia. Other medications include baclofen, phenytoin, oxacarbazepine, and gabapentin.
There are many drawbacks and side effects to these medications. Some patients may need relatively high doses to alleviate the pain and the side effects can become more pronounced at higher doses. Anticonvulsant drugs may lose their efficacy over time. Many of these drugs can have a toxic effect on some patients. Patients often have to have their blood monitored regularly.
Trigeminal Neuralgia Surgery
If medications have proven ineffective in treating trigeminal neuralgia, there are several surgical procedures which may help control the pain. Surgical treatment is divided into two categories: percutaneous (through the skin) and open. In general, percutaneous approaches are only considered in older or medically frail patients or in patients with multiple sclerosis. The open approach is recommended for younger and healthier patients. All of the procedures have varying success rates and some side effects, such as recurrence of pain and facial numbness.
Microvascular decompression involves microsurgical exposure of the trigeminal nerve root, identification of a blood vessel that may be compressing the nerve, and gentle placement of a Teflon sponge between the artery and the nerve, which decompresses the nerve. This reduces sensitivity and allows the trigeminal nerve to recover and return to a normal, pain-free condition. This is generally the most effective treatment with excellent long-term results. It also is non-destructive, with the lowest rates of numbness. Although invasive, your surgeons at Texas Spine and Neurosurgery Center have special training in this procedure and the complication rates are low. It is the preferred approach in younger patients. Pain relief is often immediate.
Percutaneous stereotactic rhizotomy treats trigeminal neuralgia by burning the nerve. It can relieve nerve pain by destroying the part of the nerve that causes pain and by suppressing the pain signal to your brain. The surgeon passes needle through the skin of your cheek into the trigeminal nerve. A heating current, which is passed through the electrode, destroys some of the nerve fibers. Unfortunately, it is destructive and has a high incidence of facial numbness, and also may cause a different type of facial pain as a side effect (anesthesia dolorosa). As a result of these limitations, we rarely recommend this form of treatment.
Gamma Knife Surgery for Trigeminal Neuralgia
Gamma Knife radiosurgery delivers a single highly concentrated dose of radiation to a small, precise target at the trigeminal nerve root ganglion. It is noninvasive and avoids many of the risks of open surgery and other treatments. It is generally safer than surgery but does not work immediately. The benefit occurs over a period of weeks. Also, due to the relative newness of the procedure, the long-term results are less well studied than open surgery.
Trigeminal Neuralgia Consultation
The Houston neurosurgeons at the Texas Spine & Neurosurgery Center are skilled in the treatment of trigeminal neuralgia. Dr. Bindal, Dr. Park , and Dr. Wang have significant skill in microvascular decompression. Dr. Park also has training in Gamma Knife radiosurgery for trigeminal neuralgia. Your doctors will discuss the best treatment strategy for you. Call today to schedule your consultation – (281) 313-0031.