Trigeminal Neuralgia

Trigeminal neuralgia is a rare neurological disorder that has been called one of the most painful conditions a person can experience. The disorder occurs when a part of the trigeminal nerve, which is located in the head and face, becomes irritated or compressed near the brain stem. The trigeminal nerve carries touch, pain, temperature, and pressure sensations from the face to the brain. When something compresses or otherwise irritates the nerve, it causes other nerves within it to misfire. The result is excruciating pain that people liken to a lightning bolt of pain or having live electrical wires in their face.

Trigeminal neuralgia can occur at any age but is most common at ages 50 and older and is rare in people younger than 40.

Spontaneous remission of the disorder is rare, but treatment can reduce or eliminate the pain.

WHAT ARE THE SYMPTOMS?

The facial pain of trigeminal neuralgia is typically shooting, stabbing, sharp, and agonizing and occurs anywhere between the forehead and jaw. The sudden pain occurs on one side of the face (usually the right side) although it affects both sides of the face infrequently. The length of painful episodes ranges from seconds to 1 hour, usually with brief bursts of pain every few seconds.

People with trigeminal neuralgia may also experience the following symptoms:

Facial pulling;
Facial fullness;
Cheek twitch or muscle spasm;
Facial flush;
Tearing eye;
Wincing; or
Salivating on the affected side of face.

Some episodes of trigeminal neuralgia pain happen spontaneously. Others occur because of a reaction to a trigger, such as speaking, chewing, or even feeling a breeze on the face. People tend to experience painful episodes of trigeminal neuralgia over several days, weeks, or months and then have a symptom-free period of weeks, months, or years before the next attack. Fear of an impending attack can severely affect a person's quality of life, as can neglecting hygiene, fasting, and avoiding social activities so as not to trigger an attack.

CAUSES AND RISK FACTORS

In most cases, trigeminal neuralgia is caused by an artery or vein pressing on the trigeminal nerve.

Risk factors for trigeminal neuralgia include:

Family history of the disease;
Age older than 50;
Female gender; and
Diagnosis of hemifacial spasm.

DIAGNOSIS

There is no specific test to confirm diagnosis, but the following tests may be performed to help determine if a patient has trigeminal neuralgia:

Pain scale, such as the Wong-Baker Faces pain rating;
Cranial magnetic resonance imaging (MRI);
MR angiography;
Opioidergic imaging; and
Electrophysiological investigation.

In addition, if a patient is given the anticonvulsant carbamazepine (Tegretol) and experiences reduced symptoms, it is likely the patient has trigeminal neuralgia. TREATMENT APPROACH

The goal of treatment for trigeminal neuralgia is to reduce or eliminate facial pain. Treatment is often successful with approximately 80 percent of patients becoming free of symptoms with medication. Medication is the first line of treatment and carbamazepine is usually tried first. Other medications used to treat trigeminal neuralgia are:

Phenytoin (Dilantin);
Gabapentin (Neurontin);
Oxcarbazepine (Trileptal); and
Baclofen (Liorsal).

If medication doesn't work, stops working, or if the side effects are too unpleasant, a combination of medication and surgery or surgery alone may be an option. With surgery, neurosurgeons aim to decompress, damage, or destroy the misfiring portion of the trigeminal nerve. There are a variety of surgical procedures used:

Percutaneous glycerol rhizotomy;
Percutaneous balloon compression of the trigeminal nerve;
Percutaneous stereotactic radiofrequency thermal rhizotomy;
Microvascular decompression; and
Percutaneous sensory rhizotomy.

These procedures may offer some pain relief, but may have to be performed several times during a person's life.

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