Facial pain and Trigeminal Neuralgia -- December 12, 2011 -- Dr. - NewsChannel5.com | Nashville News, Weather & Sports

Facial pain and Trigeminal Neuralgia -- December 12, 2011 -- Dr. Robert Mercile and Dr. John Witt

John Witt, MD: neurologist (MTMC)

TOPIC: Facial Pain and Trigeminal Neuralgia
Robert Mericle, MD: neurosurgeon (Baptist Hospital)

Monday, December 12, 2011

news notes via www.webmd.com, www.newschannel5.com, www.mayoclinic.com, www.gammaknife.org

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.

Some patients report having reduced or relieved pain by means of alternative medical therapies such as acupuncture, chiropractic adjustment, self-hypnosis or meditation.

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.

• Although a flurry of attacks can last for weeks or months, there are usually periods of months or even years that are symptom-free. The pain of tic douloureux is usually controlled with medications or surgery.
• Tic douloureux is generally a disease of middle age or later life. Women are affected more often than men. People with multiple sclerosis are affected much more frequently than the general population.

Tic Douloureux Causes

The cause of tic douloureux is unknown. There are a number of theories as to why the trigeminal nerve is affected.

• The most commonly accepted theory is compression of the trigeminal nerve, usually by a blood vessel, causing it to become irritated. This irritation causes the outer covering of the nerve (the myelin sheath) to erode over time. The irritated nerve then becomes more excitable and erratically fires pain impulses.
• Tumors and bony abnormalities of the skull may also press on and irritate the trigeminal nerve.
• Trauma, infections, and multiple sclerosis can also cause damage to the trigeminal nerve.

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.

• The pain comes in intermittent episodes that last from a few seconds to a few minutes. There may be many episodes of pain per day. There is no pain between episodes.
• The flurry of pain episodes may last from a few weeks to a few months, followed by pain-free periods of months to even years. Generally, the episodes become more frequent and more resistant to treatment with medications over time.
• The attacks of pain are often initiated by physical stimulation of a trigger point on the same side of the face as the pain. Trigger points can be anywhere on the face or in the mouth or nose. They are generally not in the same place as the pain. Stimuli that can initiate the pain include talking, eating, brushing the teeth, or even cool air on the face. There is no loss of taste, hearing, or sensation in someone suffering from tic douloureux.

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.

• The pain of tic douloureux is unique. A history of bursts of shooting pain in one side of the face along with a trigger zone will give the doctor good clues to the cause of your pain.
• The physical examination is normal in tic douloureux. If numbness, decreased hearing, dizziness, visual changes, or dysfunction of the muscles of the face is found, then other disorders may be considered. Additionally, other causes of facial pain such as a sinus infection, dental infection, or a jaw disorder, such as TMJ, can often be found by physical examination.
• Special x-ray images, such as a CT scan or MRI of the head, can look for other causes of facial pain. They can also help delineate blood vessels or tumors that might be pressing on the nerve and irritating it.

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.

Medical Treatment

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.

Medications

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.

• The most frequently prescribed anticonvulsant medication for tic douloureux is carbamazepine (Tegretol). Other anticonvulsants used include phenytoin (Dilantin) and gabapentin (Neurontin). These medications are generally started at a low dose and then increased until pain is controlled or side effects occur. Common side effects include drowsiness, dizziness, double vision, and nausea. Rarely, serious liver or bone marrow problems can occur.
• Baclofen (Lioresal), a muscle relaxant, is useful for some people who either do not respond to anticonvulsants or who suffer serious side effects.
• Opioid pain medications can be useful during episodes of severe pain.
• Medication is 80% effective. For the other 20%, drug therapy either fails to provide adequate pain control or adverse side effects are intolerable. Unfortunately, up to 50% of people who initially respond to anticonvulsants eventually develop resistance to the medications.

Surgery

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.

Follow-up

If you are diagnosed with tic douloureux, your doctor may refer you to a neurologist or neurosurgeon for management of the pain.

• Some of the medications used to treat tic douloureux may affect your blood counts and liver function, so it is important to have these levels monitored by your doctor.
• After surgery, watch for signs of infection such as redness, discharge, or fever.

Prevention: Tic douloureux cannot be prevented.

Outlook

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.

• The pain of tic douloureux can almost always be controlled with either medication or surgery.
• Most people with tic douloureux lead full, complete lives.

Resources

TNA - The Facial Pain Association
P.O. Box 340
Barnegat Light, NJ 08006
Tel: (325)331-7009
Fax: (325)331-7078
Tel: (800)923-3608
Email: patientinfo@tna-support.org
Internet: http://www.fpa-support.org/