Trigeminal Neuralgia

What is trigeminal neuralgia?

Trigeminal neuralgia is a chronic condition that is characterized by intense pain in the face. The pain can be so severe that it interferes with everyday activities. The pain may be short-lived and return sporadically, or it may be felt as a less severe but constant pain.

Trigeminal neuralgia can be triggered by activities such as talking, chewing, brushing your teeth or smiling. It typically affects one side of the face (unilateral), usually the right-hand side. In rare cases it can affect both sides (bilateral), although not at the same time.

There two main types of trigeminal neuralgia:

• Typical trigeminal neuralgia: Also called Type 1, this causes sharp, intense periods of pain that come on sporadically. The pain may be felt all over the face and last up to two minutes, with breaks in-between, with the episode lasting up to a couple of hours.
• Atypical trigeminal neuralgia: Also called Type 2, the pain is less intense but is more constant and widespread. It is often more difficult to control the symptoms with type 2 trigeminal neuralgia.

Trigeminal neuralgia is a rare disorder, and it typically affects people over 50 and is rare in the under 40s. It affects more women than men.

What causes trigeminal neuralgia?

Trigeminal neuralgia is usually caused by a blood vessel putting pressure on a nerve near the brain stem.

The trigeminal nerve is attached to the brain and is responsible for transmitting pain and touch sensations from the head and face to the brain. The trigeminal nerve has three branches which are each responsible for transmitting impulses to different parts of the face:

• Ophthalmic branch: The forehead and top portion of the face.
• Maxillary branch: The middle of the face, including nostrils, top lip and cheeks.
• Mandibular branch: The lower part of the face, including the jaw and lower lip.

People with Multiple Sclerosis may develop trigeminal neuralgia. MS and trigeminal neuralgia both cause the protective coating of nerves, called the myelin sheath, to deteriorate. People with MS may develop trigeminal neuralgia after their MS diagnosis. If someone under 40 years of age develops trigeminal neuralgia, then doctors may recommend testing for MS.

Trigeminal neuralgia can be caused by several other conditions such as a tumor or lesion that is putting pressure on the nerves. Damaging the trigeminal nerve, through surgery, trauma to the face, or stroke, may cause pain similar to the symptoms of trigeminal neuralgia.

Sometimes, the cause of trigeminal neuralgia is not known.

What are the symptoms of trigeminal neuralgia?

Symptoms of trigeminal neuralgia include:

• A burning feeling covering one side of the face
• Episodes triggered by simple activities (talking or chewing)
• Jolts of pain that feel like a stabbing pain.

Symptoms felt in the jaw and cheek area may include:

• Numbness/tingling
• Short, severe pain
• Regular aches and pains.

How is trigeminal neuralgia diagnosed?

Your doctor will first discuss symptoms and medical history with you in detail. They will also examine the head and neck area. A diagnosis will take into consideration the type of pain felt, where it is being felt and what triggers the episodes.

Many conditions have similar symptoms to trigeminal neuralgia, so your doctor will want to rule these out to confirm a diagnosis.

A neurological exam may be performed, which will look at the nerves in the brain and how the motor system is functioning. An MRI may be performed to rule out MS, brain tumors and other conditions.

How is trigeminal neuralgia treated?

The symptoms of trigeminal neuralgia can be treated with medications, surgery and complementary therapies.

Medications

• Anticonvulsant drugs: The first choice to treat trigeminal neuralgia, anticonvulsant drugs can relieve pain but may be associated with side effects, including nausea, dizziness and drowsiness.
• Tricyclic antidepressants: Usually used to treat the symptoms of Type 2 trigeminal neuralgia.
• Muscle relaxants.
• Nerve blocks: Botulinum toxin (botox) can be injected to block sensory nerves and can provide temporary relief.

Surgery

For people who don’t respond well to medication, surgery may be an option. The procedure offered will depend on the severity of pain, personal preference and other factors such as overall health. Surgery may only offer temporary relief and can causes side effects such as facial numbness.

Balloon compression: A tube (cannula) is inserted through the skin of the cheek to the trigeminal nerve. A catheter with a small balloon is inserted and as the balloon is inflated, it compresses the nerve and damages the fibers that are causing the pain. Balloon compression can relieve symptoms for up to 2 years.

Glycerol injection rhizotomy: Glycerol is injected into the root of the trigeminal nerve. This causes damage and prevents the body from transmitting pain signals to the brain. It can relieve symptoms for up to 2 years.

Radiofrequency thermal lesioning: A needle is inserted into the cheek and up to the base of your skull. An electrical current is used to find the specific pain point on the trigeminal nerve. Heat is applied to the nerve which destroys some of the nerve fibers. Symptoms can reappear after 3 to 4 years.

Microvascular decompression: A more invasive procedure, this aims to offer longer-term relief as the trigeminal nerve returns to a more pain-free state. A surgeon exposes the nerve by creating an opening behind the ear, and exposes the blood vessel that is compressing the nerve. A cushion is then placed between the blood vessel and nerve to alleviate the pressure. Microvascular decompression is usually the most successful procedure and can offer relief for up to 10 years.

Neurectomy: If the blood vessel responsible for the compression isn’t located during a microvascular decompression, this procedure may be performed. The surgeon cuts a part of the nerve close to the brain stem or nerve branches in the face. Facial nerves can grow back so pain may return in the future.

Stereotactic radiosurgery: This delivers a concentrated beam of radiation to the trigeminal nerve root, at the point where it meets the brain stem. Following the procedure, a lesion forms and disrupts the nerves’ ability to transmit pain signals. Stereotactic radiosurgery usually offers relief from symptoms for 3 years.