What is Trigeminal Neuralgia (TN)?
Trigeminal neuralgia is a chronic pain condition that affects the trigeminal nerve, which carries sensation from your face to your brain. If you have trigeminal neuralgia, even mild stimulation of your face — such as from brushing your teeth or putting on makeup — may trigger a jolt of excruciating pain.
You may initially experience short, mild attacks. But trigeminal neuralgia can progress and cause longer, more-frequent bouts of searing pain. Trigeminal neuralgia affects women more often than men, and it's more likely to occur in people who are older than 50.
Because of the variety of treatment options available, having trigeminal neuralgia doesn't necessarily mean you're doomed to a life of pain. Doctors usually can effectively manage trigeminal neuralgia with medications, injections or surgery.
Before Trigeminal Neuralgia Treatment
What is the trigeminal nerve?
The trigeminal nerve is responsible for transmitting sensations of touch and pain from the face and head to the brain. The trigeminal nerve has three branches. One branch carries nerve impulses from the forehead, upper eyelids, and eyes to the brain. The second branch is responsible for sensation in the lower eyelids, cheeks, nostrils, upper lip, and upper gum. The third branch serves the lower lip, lower gum, jaws, and some muscles used for chewing.
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Symptoms of Trigeminal Neuralgia
Trigeminal neuralgia symptoms may include one or more of these patterns:
. Episodes of severe, shooting or jabbing pain that may feel like an electric shock
. Spontaneous attacks of pain or attacks triggered by things such as touching the face, chewing, speaking or brushing teeth.
. Bouts of pain lasting from a few seconds to several minutes
. Episodes of several attacks lasting days, weeks, months or longer — some people have periods when they experience no pain.
. Constant aching, burning feeling that may occur before it evolves into the spasm-like pain of trigeminal neuralgia.
. Pain in areas supplied by the trigeminal nerve, including the cheek, jaw, teeth, gums, lips, or less often the eye and forehead.
. Pain affecting one side of the face at a time, though may rarely affect both sides of the face.
. Pain focused in one spot or spread in a wider pattern
. Attacks that become more frequent and intense over time
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Read more about : Treatment for trigeminal neuralgia
When to see a doctor
If you experience facial pain, particularly prolonged or recurring pain or pain unrelieved by over-the-counter pain relievers, see your doctor.
In trigeminal neuralgia, also called tic douloureux, the trigeminal nerve's function is disrupted. Usually, the problem is contact between a normal blood vessel — in this case, an artery or a vein — and the trigeminal nerve at the base of your brain. This contact puts pressure on the nerve and causes it to malfunction.
Trigeminal neuralgia can occur as a result of aging, or it can be related to multiple sclerosis or a similar disorder that damages the myelin sheath protecting certain nerves. Trigeminal neuralgia can also be caused by a tumor compressing the trigeminal nerve.
Some people may experience trigeminal neuralgia due to a brain lesion or other abnormalities. In other cases, surgical injuries, stroke or facial trauma may be responsible for trigeminal neuralgia.
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A variety of triggers may set off the pain of trigeminal neuralgia, including:
. Touching your face
. Brushing your teeth
. Putting on makeup
. Encountering a breeze
. Washing your face
How common is trigeminal neuralgia (TN)?
About 150,000 new cases of trigeminal neuralgia are diagnosed each year. It is more likely to occur in people over age 50, although people of any age may be affected. Typical trigeminal neuralgia is rare in people less than 40 years old. Multiple sclerosis should be considered in younger patients with TN. The incidence of trigeminal neuralgia in patients with MS is 1% to 2%.
Your doctor will diagnose trigeminal neuralgia mainly based on your description of the pain, including:
. Type. Pain related to trigeminal neuralgia is sudden, shock-like and brief.
. Location. The parts of your face that are affected by pain will tell your doctor if the trigeminal nerve is involved.
. Triggers. Trigeminal neuralgia-related pain usually is brought on by light stimulation of your cheeks, such as from eating, talking or even encountering a cool breeze.
Your doctor may conduct many tests to diagnose trigeminal neuralgia and determine underlying causes for your condition, including:
. A neurological examination. Touching and examining parts of your face can help your doctor determine exactly where the pain is occurring and — if you appear to have trigeminal neuralgia — which branches of the trigeminal nerve may be affected. Reflex tests also can help your doctor determine if your symptoms are caused by a compressed nerve or another condition.
. Magnetic resonance imaging (MRI). Your doctor may order an MRI scan of your head to determine if multiple sclerosis or a tumor is causing trigeminal neuralgia. In some cases, your doctor may inject a dye into a blood vessel to view the arteries and veins and highlight blood flow (magnetic resonance angiogram).
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.
There are no guidelines for preventing the development of trigeminal neuralgia. However, the following steps may help prevent attacks once diagnosed:
. Eating soft foods
. Avoiding foods that are too cold or hot
. Washing your face with lukewarm water
. Using cotton pads when washing your face
. If tooth brushing triggers an attack, rinsing your mouth with lukewarm water after eating.
. As far as possible, avoiding known triggers
Trigeminal neuralgia can be debilitating, but managing the symptoms can drastically improve the quality of life.
During Trigeminal Neuralgia Treatment
What are the types of trigeminal neuralgia (TN)?
There are two main forms of TN:
. Typical (Type 1) TN: Symptoms include sudden or sporadic periods of intense facial pain or burning. Attacks can last from a few seconds to a few minutes. Painful episodes occur in rapid succession and may continue for a few hours, but there are generally pain-free periods between attacks.
. Atypical (Type 2) TN: The atypical form is characterized by constant pain, with stabbing, burning or aching sensations that may be less intense but more widespread than those associated with Type 1. Symptoms may also be more difficult to control.
Trigeminal neuralgia treatment usually starts with medications, and some people don't need any additional treatment. However, over time, some people with the condition may stop responding to medications, or they may experience unpleasant side effects. For those people, injections or surgery provide other trigeminal neuralgia treatment options.
If your condition is due to another cause, such as multiple sclerosis, your doctor will treat the underlying condition.
To treat trigeminal neuralgia, your doctor usually will prescribe medications to lessen or block the pain signals sent to your brain.
. Anticonvulsants. Doctors usually prescribe carbamazepine (Tegretol, Carbatrol, others) for trigeminal neuralgia, and it's been shown to be effective in treating the condition. Other anticonvulsant drugs that may be used to treat trigeminal neuralgia include oxcarbazepine (Trileptal), lamotrigine (Lamictal) and phenytoin (Dilantin, Phenytek). Other drugs, including clonazepam (Klonopin) and gabapentin (Neurontin, Gralise, others), also may be used.
If the anticonvulsant you're using begins to lose effectiveness, your doctor may increase the dose or switch to another type. Side effects of anticonvulsants may include dizziness, confusion, drowsiness and nausea. Also, carbamazepine can trigger a serious drug reaction in some people, mainly those of Asian descent, so genetic testing may be recommended before you start carbamazepine.
. Antispasmodic agents. Muscle-relaxing agents such as baclofen (Gablofen, Lioresal) may be used alone or in combination with carbamazepine. Side effects may include confusion, nausea and drowsiness.
. Botox injections. Small studies have shown that onabotulinumtoxinA (Botox) injections may reduce pain from trigeminal neuralgia in people who are no longer helped by medications. However, more research needs to be done before this treatment is widely used for this condition.
Surgical options for trigeminal neuralgia include:
. Microvascular decompression. This procedure involves relocating or removing blood vessels that are in contact with the trigeminal root to stop the nerve from malfunctioning. During microvascular decompression, your doctor makes an incision behind the ear on the side of your pain. Then, through a small hole in your skull, your surgeon moves any arteries that are in contact with the trigeminal nerve away from the nerve, and places a soft cushion between the nerve and the arteries.
If a vein is compressing the nerve, your surgeon may remove it. Doctors may also cut part of the trigeminal nerve (neurectomy) during this procedure if arteries aren't pressing on the nerve.
Microvascular decompression can successfully eliminate or reduce pain most of the time, but pain can recur in some people. Microvascular decompression has some risks, including decreased hearing, facial weakness, facial numbness, a stroke or other complications. Most people who have this procedure have no facial numbness afterward.
. Brain stereotactic radiosurgery (Gamma knife). In this procedure, a surgeon directs a focused dose of radiation to the root of your trigeminal nerve. This procedure uses radiation to damage the trigeminal nerve and reduce or eliminate pain. Relief occurs gradually and may take up to a month.
Brain stereotactic radiosurgery is successful in eliminating pain for the majority of people. If pain recurs, the procedure can be repeated. Facial numbness can be a side effect.
Other procedures may be used to treat trigeminal neuralgia, such as a rhizotomy. In a rhizotomy, your surgeon destroys nerve fibers to reduce pain, and this causes some facial numbness. Types of rhizotomy include:
. Glycerol injection. During this procedure, your doctor inserts a needle through your face and into an opening in the base of your skull. Your doctor guides the needle into the trigeminal cistern, a small sac of spinal fluid that surrounds the trigeminal nerve ganglion — where the trigeminal nerve divides into three branches — and part of its root. Then, your doctor will inject a small amount of sterile glycerol, which damages the trigeminal nerve and blocks pain signals.
This procedure often relieves pain. However, some people have a later recurrence of pain, and many experience facial numbness or tingling.
. Balloon compression. In balloon compression, your doctor inserts a hollow needle through your face and guides it to a part of your trigeminal nerve that goes through the base of your skull. Then, your doctor threads a thin, flexible tube (catheter) with a balloon on the end through the needle. Your doctor inflates the balloon with enough pressure to damage the trigeminal nerve and block pain signals.
Balloon compression successfully controls pain in most people, at least for a period of time. Most people undergoing this procedure experience at least some transient facial numbness.
. Radiofrequency thermal lesioning. This procedure selectively destroys nerve fibers associated with pain. While you're sedated, your surgeon inserts a hollow needle through your face and guides it to a part of the trigeminal nerve that goes through an opening at the base of your skull.
Once the needle is positioned, your surgeon will briefly wake you from sedation. Your surgeon inserts an electrode through the needle and sends a mild electrical current through the tip of the electrode. You'll be asked to indicate when and where you feel tingling.
When your neurosurgeon locates the part of the nerve involved in your pain, you're returned to sedation. Then the electrode is heated until it damages the nerve fibers, creating an area of injury (lesion). If your pain isn't eliminated, your doctor may create additional lesions.
Radiofrequency thermal lesioning usually results in some temporary facial numbness after the procedure. Pain may return after three to four years.
Other approaches that may be used in conjunction with drug therapy include:
. Creative visualization
. Aroma therapy
. Low-impact exercise
Additional therapies that may be helpful include:
. Supportive counseling or therapy
. Vitamin therapy
. Nutritional therapy
After Trigeminal Neuralgia Treatment
Recovery from Surgery
If you have had surgery for trigeminal neuralgia, the recovery process depends on the type of surgical procedure. Pain relief can be immediate after most percutaneous procedures, but it may be weeks or months after gamma knife surgery before pain subsides. You may have some facial numbness following percutaneous procedures, but most treated people report that this numbness is easier to tolerate than the pain they previously experienced. Follow-up appointments with your doctor occur in the three to six months after you’ve had a gamma knife or percutaneous procedure.
Microvascular decompression surgery often provides rapid pain relief. You may have to take medication for two to four weeks after the procedure to ease any discomfort and swelling and to guard against infection. Your doctor slowly decreases your use of these medications after about a month. Stitches at the incision site are typically removed about 10 days after the procedure. Most people are able to return to work and daily activities about a month after surgery.
Although no procedure is guaranteed to cure trigeminal neuralgia, all types of trigeminal neuralgia surgery have the potential to stop pain for many years, if not permanently. Some surgical procedures can also be repeated if the pain returns. If pain does return after surgery, it may be more easily treated with medications.