Trigeminal neuralgia (TN), also called tic douloureux, is a chronic pain condition that affects the trigeminal or 5th cranial nerve, one of the most widely distributed nerves in the head. TN is a form of neuropathic pain (pain associated with nerve injury or nerve lesion.) The typical or “classic” form of the disorder (called “Type 1” or TN1) causes extreme, sporadic, sudden burning or shocklike facial pain that lasts anywhere from a few seconds to as long as two minutes per episode. These attacks can occur in quick succession, in volleys lasting as long as two hours. The “atypical” form of the disorder (called “Type 2” or TN2), is characterized by constant aching, burning, stabbing pain of somewhat lower intensity than Type 1. Both forms of pain may occur in the same person, sometimes at the same time. The intensity of pain can be physically and mentally incapacitating.
The trigeminal nerve is one of 12 pairs of nerves that are attached to the brain. The nerve has three branches that conduct sensations from the upper, middle, and lower portions of the face, as well as the oral cavity, to the brain. The ophthalmic, or upper, branch supplies sensation to most of the scalp, forehead, and front of the head. The maxillary, or middle, branch stimulates the cheek, upper jaw, top lip, teeth and gums, and to the side of the nose. The mandibular, or lower, branch supplies nerves to the lower jaw, teeth and gums, and bottom lip. More than one nerve branch can be affected by the disorder. Rarely, both sides of the face may be affected at different times in an individual, or even more rarely at the same time (called bilateral TN).
TN is associated with a variety of conditions. TN can be caused by a blood vessel pressing on the trigeminal nerve as it exits the brain stem. This compression causes the wearing away or damage to the protective coating around the nerve (the myelin sheath). TN symptoms can also occur in people with multiple sclerosis, a disease that causes deterioration of the trigeminal nerve’s myelin sheath.Symptoms of TN may be caused by nerve compression from a tumor, or a tangle of arteries and veins called an arteriovenous malformation. Injury to the trigeminal nerve (perhaps the result of sinus surgery, oral surgery, stroke, or facial trauma) may also produce neuropathic facial pain.
Trigeminal neuralgia pain caused by a lesion, such as a tumor, is referred to as secondary trigeminal neuralgia. A tumor that severely compresses or distorts the trigeminal nerve may cause facial numbness, weakness of chewing muscles, and/or constant aching pain. Medications usually help control secondary TN pain when first tried, although often become. Surgically removing the tumor usually alleviates pain and trigeminal function may return. At the time of surgery, after the removal of the tumor, the trigeminal nerve may be found to also be compressed by an artery or vein that causes the typical features of TN. This vessel must then be moved away from the nerve by microvascular decompression techniques to cure TN.
Your doctor will diagnose trigeminal neuralgia mainly based on your description of the pain, including:
Your doctor may conduct many tests to diagnose trigeminal neuralgia and determine underlying causes for your condition, including:
Your facial pain may be caused by many different conditions, so an accurate diagnosis is important. Your doctor may order additional tests to rule out other conditions.
Trigeminal neuralgia is treated on an outpatient basis, unless neurosurgical intervention is required. Management of this condition must be tailored individually, based on the patient’s age and general condition. In the case of symptomatic trigeminal neuralgia, adequate treatment is that of its cause, the details of which are out of the scope of this article.
Because most patients incur trigeminal neuralgia when older than 60 years, medical management is the logical initial therapy. Medical therapy is often sufficient and effective, allowing surgical consideration only if pharmacologic treatment fails. Medical therapy alone is adequate treatment for 75% of patients.
Patients may find immediate and satisfying relief with one medication, typically carbamazepine. However, because this disorder may remit spontaneously after 612 months, patients may elect to discontinue their medication in the first year following the diagnosis. Most must restart medication in the future. Furthermore, over the years, they may require a second or third drug to control breakthrough episodes and finally may need surgical intervention.
Simpler, less invasive procedures are well tolerated but usually provide only shortterm relief. At this point, further and perhaps more invasive operations may be required, and with these procedures the risk of the disabling adverse effect of anesthesia dolorosa increases.
Thus, treatment can be subdivided into pharmacologic therapy, percutaneous procedures, surgery, and radiation therapy. Adequate pharmacologic trials should always precede the contemplation of a more invasive approach.
Transcranial magnetic stimulation appears promising, but results are still scarce.
Adjunct treatments such as mechanical, electrical, and thermal stimuli sometimes modify pain with fewer adverse effects than medication. Selfadhesive bandages may also be used.
Depression is often seen in patients with trigeminal neuralgia; thus, this underlying depression should be adequately treated. Tricyclic antidepressants (eg, amitriptyline, nortriptyline), as well as sodium valproate or pregabalin, have not been well studied. Amitriptyline (Elavil) can be tried, but the success rate is low.
Trigeminal neuralgia (TN) is a disorder of the 5th cranial nerve. TN causes sudden shock-like facial pains, typically near the nose, lips, eyes or ears. It is said to be the most excruciatingly painful human condition in the world. TNA’s origin is unknown, but it is often attributed to abnormal blood vessels that compress the nerve, multiple sclerosis, or tumors. The disorder is named for the three-part (trigeminal) nerve that supplies sensations to all parts of the face.
TN is characterized by jolting, stabbing, or electrocution-type pains, neuropathic facial pain is better described as constant, dull, burning or boring pain with intermittent sharp stabbing pains. Numbness and tingling may also be present with neuropathic facial pain.
TN was first described in medical literature as early as 1672. Some people know the disorder as Tic Douloureux. TN is often misdiagnosed as a toothache or TMJ. Many people go undiagnosed for years. Some people are misdiagnosed with TN although what they have is actually neuropathic facial pain.
Sometimes injury to the end of the trigeminal nerve is caused by some type of trauma, such as a dental procedure or a blow to the face. Post herpetic neuralgia, better known as shingles, occurs after a herpetic breakout. The pain of neuropathic pain is usually constant, but can fluctuate in intensity. The pain is usually described as burning, aching or tightness. Many times numbness is present. This type of pain is difficult to treat and the procedures for classic TN can make this type of pain worse.
TN is often caused by loss of or damage to the nerve’s protective coating, myelin. The most widely accepted view is that myelin damage results from irritation of the nerve, usually a blood vessel that causes the nerve to be compressed. Multiple sclerosis lesions and abnormal growths can also cause TN. Other types of facial pain can be caused by an outbreak of shingles or a similar virus or an injury to the nerve.
TN is diagnosed almost exclusively by the individual’s description of the symptoms. To rule out other sources of facial pain, doctors typically order a magnetic resonance imaging (MRI) scan when TN is suspected, but that’s done to check for multiple sclerosis or a tumor that might be causing the pain. Compression of the nerve by a vessel can sometimes be seen on a MRI.
Yes, both disorders are considered impairments, which can limit an individual’s ability to function on the job.
Some people are encouraged when they talk to others who have experienced facial pain. TNA has support networks, offering people the chance to share their experiences with one another. Counseling can sometimes help an individual to sort through the stress and isolation that can accompany facial pain.
Yes, it is normally treated with anticonvulsants. Tegretol (carbamazepine) is often the most effective treatment. Some of the other medications that are commonly prescribed are Dilantin, Carbatrol, Trileptal, and Lyrica. If these medications become ineffective or the side-effects become intolerable, surgical treatment may be offered.
Some side effects may go away as your body adjusts to the medicine. Tell your healthcare provider if you have any side effects that continue or get worse.
Sometimes, but it’s not likely. TN pain typically runs in cycles, and it is common for individuals with TN to experience periods of remission. Remission can last for weeks, months, and even years. Over time, the attacks tend to worsen with fewer and shorter pain-free periods.
Several types of surgical procedures are available.
Microvascular Decompression Surgery (MVD): This procedure removes the cause of the TN pain. The MVD offers the best chance of long-term relief without damaging the nerve. The goal of the neurosurgeon is to lift the offending vessel from the trigeminal nerve by placing a padding between them. This procedure requires a craniotomy (surgical removal of a section of bone from the skull for the purpose of operating on the underlying tissues) and has the longest recovery time.
Damaging the nerve: Several procedures can be done to stop the transmission of pain signals to the brain. These procedures actually cause damage to the nerve and can be effective for varying lengths of time. Procedures that go through the cheek with a needle are glycerol injections, balloon compression, and radiofrequency lesioning. They can be done in the X-ray suite or the operating room. Sterotactic radiosurgery uses highly focused beams of radiation, causes a slow formation of a lesion in the nerve over a period of time to interrupt the pain transmission.
It is important to be informed about possible risks or side-effects and what to expect the first week or so after surgery. Some procedures may take months before the individual with trigeminal neuralgia notices the results, so you may want to ask your doctor how much time it will take to know if your procedure has helped your pain. Another important thing to ask is what the surgeon’s success rates with this procedure are. You can follow up that question by asking what results the surgeon considers to be successful as well as unsuccessful.
Medications sometimes help control neuropathic facial pain. People with neuropathic facial pain may be prescribed anticonvulsants such as Lyrica or Neurontin. Anti-depressants, such as Elavil or Cymbalta, can also help with the pain. Complementary Alternative Medical (CAM) treatments can also be helpful.
Many people find that complementary alternative medical (CAM) treatments can bring some relief. These therapies include things like upper cervical chiropractic (UCC), acupuncture, herbal remedies and vitamins, or special diets.