John Witt, MD: neurologist (MTMC)
TOPIC: Facial Pain and Trigeminal Neuralgia
Robert Mericle, MD: neurosurgeon (Baptist Hospital)
Monday, December 12, 2011
It's a pain that can be triggered by something as simple as a cool breeze or a bite of food. One in 15,000 people have trigeminal neuralgia - a disease that's misdiagnosed as everything from dental pain to migraines. Now, highly-targeted surgical treatments are helping these patients when no medicine can.
For one patient, a single brush of makeup used to be enough to send a searing jolt of pain into the right side of her face.
"It burns like fire. It's like electricity at the same time. Just too scary. You didn't want to set it off," the trigeminal neuralgia patient said.
For 15 years, the slightest touch could trigger excruciating pain. No medication helped.
"I went to a support group because I was going to kill myself" the patient added.
It's called Trigeminal Neuralgia - a disorder of the nerve that supplies sensation to the face.
BACKGROUND: 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. Only one in 15,000 people have it. (Source: Mayoclinic)
CAUSES: In trigeminal neuralgia, 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. (Source: Mayoclinic)
TREATMENT: Treatment usually starts with medications, and many people require no additional therapy. However, over time, some people with the disorder eventually stop responding to medications, or they experience unpleasant side effects. For those people, injections or surgery provide other trigeminal neuralgia treatments options. (Source: Mayoclinic)
GAMMA KNIFE RADIOSURGERY: The Gamma Knife unit aims 201 narrow "pencil beams" of radioactive cobalt-60 at the trigeminal nerve, focusing precisely on the target and minimizing radiation effects to surrounding healthy tissues. Because radiosurgery is the least invasive procedure for trigeminal neuralgia, it is a good treatment option for patients with co-morbidities, high-risk medical illness, or pain refractory to prior surgical procedures. (Source: GammaKnife.org)
MICROVASCULAR DECOMPRESSION: The reason for trigeminal neuralgia is presumed to be an abnormal blood vessel pressing over the fifth nerve at the site of origin. To prevent the pressure effects, a Teflon pad is interposed between the blood vessel and the nerve. Once the pressure is relieved over the nerve, the neural transmission is supposed to return to normal. It has been reported to provide immediate complete relief in 79 percent of patients. (Source: Mayfield Clinic)
What is Trigeminal Neuralgia?
Trigeminal neuralgia (TN), also called tic douloureux, is a condition that is characterized by intermittent, shooting pain in the face.
Trigeminal neuralgia affects the trigeminal nerve, one of the largest nerves in the head. The trigeminal nerve sends impulses of touch, pain, pressure, and temperature to the brain from the face, jaw, gums, forehead, and around the eyes.
Trigeminal neuralgia, also known as tic douloureux, is a disorder of the fifth cranial nerve (trigeminal nerve) characterized by attacks of intense, stabbing pain affecting the mouth, cheek, nose, and/or other areas on one side of the face. The exact cause of trigeminal neuralgia is not fully understood.
What Causes Trigeminal Neuralgia?
The most frequent cause of trigeminal neuralgia is a blood vessel pressing on the nerve near the brain stem. Over time, changes in the blood vessels of the brain can result in blood vessels rubbing against the trigeminal nerve root. The constant rubbing with each heartbeat wears away the insulating membrane of the nerve, resulting in nerve irritation.
What Are the Symptoms of Trigeminal Neuralgia?
Trigeminal neuralgia causes a sudden, severe, electric shock-like, or stabbing pain that lasts several seconds. The pain can be felt on the face and around the lips, eyes, nose, scalp, and forehead. Symptoms can be brought on when a person is brushing the teeth, putting on makeup, touching the face, swallowing, or even feeling a slight breeze.
Trigeminal neuralgia is often considered one of the most painful conditions seen in medicine. Usually, the pain is felt on one side of the jaw or cheek, but some people experience pain at different times on both sides. The attacks of pain may be repeated one after the other. They may come and go throughout the day and last for days, weeks, or months at a time. At times, the attacks can disappear for months or years. The disorder is more common in women than in men and rarely affects anyone younger than 50.
How Is Trigeminal Neuralgia Diagnosed?
Magnetic resonance imaging (MRI) can be used to determine whether a tumor or multiple sclerosis is irritating the trigeminal nerve. Otherwise, no test can determine with certainty the presence of trigeminal neuralgia. Tests can, however, help rule out other causes of facial disorders. Trigeminal neuralgia usually is diagnosed based on the patient's description of the symptoms.
How Is Trigeminal Neuralgia Treated?
Trigeminal neuralgia can be treated with antiseizure medications such as Tegretol or Neurontin. The medications Klonopin and Depakote may also be effective and may be used in combination with other drugs to achieve pain relief. Some antidepressant drugs also have significant pain relieving effects.
If medications are ineffective or if they produce undesirable side effects, neurosurgical procedures are available to relieve pressure on the nerve or to reduce nerve sensitivity.
Tic Douloureux or Trigeminal Neuralgia
Tic Douloureux Overview
Tic douloureux or trigeminal neuralgia is a severe, stabbing pain to one side of the face. It stems from one or more branches of the nerve that supplies sensation to the face, the trigeminal nerve. It is considered one of the most painful conditions to affect people.
The pain usually lasts from a few seconds to a few minutes. It may be so intense that you wince involuntarily, hence the term tic. There is usually no pain or numbness between attacks and no dysfunction of the muscles of the face.
Most people feel the pain in their jaw, cheek, or lip on one side of the face only. Pain is usually triggered by a light touch of the face or mouth on the same side as the pain. The pain is so severe that people can become afraid to talk, eat, or move during periods of attacks.
Tic Douloureux Causes
The cause of tic douloureux is unknown. There are a number of theories as to why the trigeminal nerve is affected.
Tic Douloureux Symptoms
The main symptom of tic douloureux is a sudden, severe, stabbing, sharp, shooting, electric-shock-like pain on one side of the face. Because the second and third divisions of the trigeminal nerve are the most commonly affected, the pain is usually felt in the lower half of the face.
When to Seek Medical Care
Call your doctor when the prescribed medications are not controlling the pain, or if you develop new symptoms. Because tic douloureux is a pain-only syndrome, the development of new symptoms may warrant additional evaluation.
Go to a hospital's emergency department if you experience symptoms such as fever, redness of your face, or dizziness. These symptoms may not be related to your condition and may signify another illness. If your prescribed medication is not relieving the pain and your doctor is not available for advice, go to the hospital.
Exams and Tests
There is no single medical test to diagnose tic douloureux. The diagnosis is made based on the description of the pain, physical examination, and exclusion of other causes of facial pain.
Tic Douloureux Treatment
Self-Care at Home
There are no effective home treatment remedies for tic douloureux. Treatment should be guided by a physician. The role of the doctor is to ensure the diagnosis, begin appropriate therapy, and coordinate any potential need for consultants. In most cases, effective treatment will require only medications. Uncommonly, surgery will be recommended.
The primary treatment of tic douloureux is medication to control the pain. Surgery may be necessary when drug therapy is not effective or side effects from the medications are not tolerable.
A number of medications are effective in helping control the pain of tic douloureux. The most commonly prescribed medications are anticonvulsants (seizure medications). Anticonvulsants help to stop the irritated trigeminal nerve from firing pain impulses.
When pain cannot be controlled with medication, surgical options should be discussed with a neurosurgeon. Surgery could range from simple injections of anesthetic into the trigeminal nerve to complex procedures that must be performed in the operating room. In general, the more complex procedures provide longer-lasting pain relief but with greater potential for more serious complications.
If you are diagnosed with tic douloureux, your doctor may refer you to a neurologist or neurosurgeon for management of the pain.
Prevention: Tic douloureux cannot be prevented.
Although pain from tic douloureux can go away without treatment for months to years, the disorder is usually progressive. Attacks can become more frequent over time. There are no long-term medical consequences of the disorder. Tic douloureux is purely a pain syndrome.
TNA - The Facial Pain Association
P.O. Box 340
Barnegat Light, NJ 08006