By Dr. Ravindra Patil
Trigeminal neuralgia (TN), is sometimes described as the most excruciating pain known to humanity. The pain typically involves the lower face and jaw, although sometimes it affects the area around the nose and above the eye. This intense, stabbing, electric shock-like pain is caused by irritation of the trigeminal nerve, a nerve in face, which sends branches to the forehead, cheek and lower jaw. It usually is limited to one side of the face. The pain can be triggered by an action as routine and minor as brushing your teeth, eating or a sudden sharp breeze. If left untreated, trigeminal neuralgia can progressively worsen. Facial neuralgia means pain on the face related to a nerve.
Trigeminal neuralgia cannot always be cured, there are treatments available to alleviate the debilitating pain. Normally, anticonvulsive medications are the first treatment choice. Surgery can be an effective option for those who become unresponsive to medications or for those who suffer serious side effects from the medications.
The trigeminal nerve is one set of the cranial nerves, which means it originates from the brain. It is the nerve responsible for providing sensation to the face. There are two trigeminal nerves, one on either side of our face. The trigeminal nerve leaves the brain and travels inside the skull, where it divides into three smaller branches, controlling sensations throughout the face:
It is reported that 150,000 people are diagnosed with trigeminal neuralgia every year. While the disorder can occur at any age, it is most common in people over the age of 50. TN is twice as common in women than in men.
There are two main forms of trigeminal neuralgia:
The exact cause of TN is still unknown, but the pain associated with it represents an irritation of the nerve. Primary trigeminal neuralgia has been linked to the compression of the nerve, typically in the base of the head where the brain meets the spinal cord. This is usually due to contact between a healthy artery or vein and the trigeminal nerve at the base of the brain. This places pressure on the nerve as it enters the brain and causes the nerve to misfire. Secondary TN is caused by pressure on the nerve from a brain lesion like a tumour, cyst, facial injury or any medical condition that damages the myelin sheaths.
Any one side face pain cannot be trigeminal neuralgia. Most patients report that their pain begins spontaneously. Other patients say their neuralgia pain came after a car accident, a blow to the face or dental work.
TN tends to run in cycles. Patients often suffer long stretches of frequent attacks, followed by weeks, months or even years of little or no pain. The pain typically begins with a sensation of electrical shocks that culminates in an excruciating stabbing pain within less than 20 seconds.
Pain can be focused in one spot or it can spread throughout the face. Typically, it is only one side face pain, eg… pain in right side of face and jaw and ear; however, in rare occasions and sometimes when associated with multiple sclerosis, patients may feel pain in both sides of their face. Pain areas include the cheeks, jaw, teeth, gums, lips, eyes and forehead.
Attacks of TN may be triggered by the following:
There are many other conditions which are similar to TN. Brain specialists use various tests to pinpoint the exact diagnosis.
TN can be very difficult to diagnose, because there are no specific diagnostic tests and symptoms are very similar to other facial pain disorders. Therefore, it is important to seek medical care when feeling unusual, sharp pain around the eyes, lips, nose, jaw, forehead and scalp, especially if you have not had dental or other facial surgery recently.
TN usually is diagnosed based on the description of the symptoms provided by the patient, detailed patient history and clinical evaluation.
There are no specific diagnostic tests for TN, so physicians must rely heavily on symptoms and history, type of pain (sudden, quick and shock-like), the location of the pain and things that trigger the pain. MRI can detect tumour/s or Multiple Sclerosis and if there is compression caused by a blood vessel. Newer scanning techniques can show if a vessel is pressing on the nerve and may even show the degree of compression.
There are several effective ways to alleviate the pain, including a variety of medications. Medications are generally started at low doses and increased gradually based on patient’s response to the drug.
Other medications include baclofen, amitriptyline, pregabalin, phenytoin, valproic acid etc.
Medicines may have side effect and may become ineffective after long usage.
If medications have proven ineffective in treating TN, several surgical procedures may help control the pain.
Microvascular decompression surgery involves microsurgical exposure of the trigeminal nerve root, identification of a blood vessel that may be compressing the nerve and gentle movement of the blood vessel away from the point of compression. Although most effective, it is also most invasive.
Percutaneous radiofrequency rhizotomy treats TN through the use of electrocoagulation (heat). It can relieve nerve pain by destroying the part of the nerve that causes pain and suppressing the pain signal to the brain.
Percutaneous balloon compression utilizes a needle that is passed through the cheek to the trigeminal nerve. The balloon compresses the nerve, injuring the pain-causing fibres, and is then removed.
Percutaneous glycerol rhizotomy utilizes glycerol injected through a needle into the area where the nerve divides into three main branches. The goal is to damage the nerve selectively in order to interfere with the transmission of the pain signals to the brain.
Stereotactic radiosurgery (through such procedures as Gamma Knife, Cyberknife, Linear Accelerator (LINAC) delivers a single highly concentrated dose of ionizing radiation to a small, precise target at the trigeminal nerve root. This treatment is non-invasive and avoids many of the risks and complications of open surgery and other treatments.
Overall, the benefits of surgery or lesioning techniques should always be weighed carefully against its risks. At Samarth Neuro and Trauma Hospital in Miraj, many patients with Trigeminal neuralgia or one side face pain have recovered after medical or surgical treatment, under the specialist care of Neurosurgeon Dr Ravindra Patil.
Samarth Neuro and Superspeciality Hospital has 100+ beds & specializes in emergency surgery for neurological issues/disorders & diagnostics.
Samarth Neuro and Superspeciality Hospital
