trigeminal neuralgia

What is trigeminal neuralgia and how is it treated?

Trigeminal neuralgia commonly known as tic douloureux is a condition in which severe sharp pain which is like an electric current is felt on the face, lips, gums cheeks, or even in the eye: in the distribution of the trigeminal nerve. It is one of the most painful conditions, that is why it is also called the suicide disease.

According to an estimate 1 in 15000 people suffer from this condition. Trigeminal neuralgia symptoms are more common in females as compared to males. Incidence of trigeminal neuralgia symptoms is highest after the age of 50 years, but people younger than this age are also found to have trigeminal neuralgia

What are the symptoms of neuralgia?

The most characteristic symptom of tic douloureux is severe facial pain which is sharp and electric current-like and comes in episodes. Each episode of pain usually lasts for a few seconds to several minutes, rarely pain may last for hours. Episodes come in paroxysms often several times a day.

Patients may describe an area over the face, which on touching can trigger an episode of intense. Other triggering factors for pain are, chewing, eating, talking, brushing the teeth, shaving, noise, and blowing of the wind. Sometimes pain starts without any stimulant factor. 

Attacks of pain are described by the patient as stabbing electric shocks, pressing over the face, severe burning sensation, crushing or shooting unbearable trigeminal nerve pain. Trigeminal neuralgia worsens the quality of life of the sufferer.

Usually, pain attacks occur on one side of the face but 10-12% of the sufferers feel pain on both sides of the facial nerve damage face treatment. Tic douloureux symptoms usually come in cycles; pain episodes continue for months then stop just to recur after a pain-free interval which may last from several months to years. In some patients, the pain worsens as time passes. 

Some patient has initially pain in one branch of the trigeminal nerve, and then gradually other branches of the trigeminal nerves are also involved. Pain in the index finger is also an accompanying feature in a small proportion of the patients suffering from tic douloureux.

Signs of trigeminal neuralgia

In most of the patients, there are no apparent signs of trigeminal nerve trigeminal dysfunction. Sensation in the distribution of the trigeminal nerve pain is usually intact except in cases of multiple sclerosis and some other systemic diseases in which sensations are lost over the face along with weakness of muscles supplied by the trigeminal nerve.

In males sometimes, they leave an area over the face while shaving that indicates the triggering zone for tic douloureux symptoms, and shaving may trigger pain.

What is the main cause of trigeminal neuralgia?

There are many theories about the pain of trigeminal neuralgia; according to the old theory, the nerve trigeminal is compressed while exiting from the skull. The newer theory stated that an enlarged blood vessel( superior cerebellar artery) throbs against the microvasculature of the trigeminal nerve pain at its connection with pons. 

This can injure the myelin sheath of the nerve trigeminal which trigeminal neuralgia cause hyperfunctioning of the nerve. This can lead to episodic pain attacks on ordinary stimulation of the area supplied by the trigeminal nerve.

Other causes of trigeminal neuralgia include:

  • Multiple sclerosis
  • Stroke
  • Tumor of posterior cranial fossa
  • Arachnoid cyst in Cerebellopontine angle
  • Aneurysm (dilatation) of blood vessel
  • Tongue piercing

If no cause is identified it is called idiopathic trigeminal neuralgia.

Diagnosis of trigeminal neuralgia

Diagnosis of trigeminal neuralgia is usually clinical however neuro-imaging like magnetic resonance imaging and magnetic resonance angiogram is performed when suspicion of multiple sclerosis, stroke, or aneurysm of the blood vessel is there. It also helps to localize the aberrant blood vessel compressing the trigeminal nerve at its exit from the pons.

Trigeminal Neuralgia Treatment

Trigeminal neuralgia has medical and surgical treatment.

Medical treatment

Medical treatment for tic douloureux include the following medication

  1. Anticonvulsants

Anticonvulsants are the mainstay of medical treatment for trigeminal neuralgia. The first line drug among anticonvulsants is carbamazepine, it is started in a low dose and the dose is increased every 2-3 days till the symptoms are controlled, it is continued for months then if symptoms are controlled for a long time, is slowly tapered.

  1. Antidepressants

Among this class of medications amitriptyline at low doses is proved efficacious in neuropathic pain, but these medications are usually reserved for depression associated with chronic pain. Duloxetine which is again an antidepressant can be used if the patient has neuropathic pain of trigeminal neuralgia and depression together.

  1. Botox

Botox which is a botulinum toxin is also a choice for the treatment of trigeminal neuralgia. It is injected into the trigeminal nerve ganglion by the physician.

  1. Neurostimulator

is another option, implanted to the patient who has its role in nerve stimulation and reducing the pain of tic douloureux.

  1. Opioid analgesics

like morphine and oxycodone,  if found helpful in relieving pain may be used.

If one drug is found ineffective, another drug of the same group or another group should be tried. Often a combination of drugs is needed to suppress the symptoms of trigeminal neuralgia. A topical preparation of gabapentin can be used in patients who don’t tolerate long-term oral medications.

Surgical treatment of trigeminal neuralgia

The surgical procedure for treating trigeminal neuralgia is based on either relieving pressure on a trigeminal nerve or destroying this nerve partially. Surgical options available include

  1. Microvascular decompression.

In this procedure neurosurgeon enters the skull, if a blood vessel is compressing the nerve, the vessel and nerve are separated in order to relieve pressure on the nerve. This procedure has got very good results.

  1. Glycerol injections

This involves injecting a cavern near the trigeminal nerve, the nerve is damaged due to its corrosive effect.

Other decompressive procedures involve advancing a needle or catheter through the mouth into the area where the trigeminal nerve is divided into three divisions. Selective destruction of the division which causes pain can be done.

  1. Gamma knife surgery

Gamma Knife is noninvasive surgery in which the trigeminal nerve is destroyed through stereotactic technique. 

  1. Radio-frequency rhizotomy

Another approach is destroying the nerve by the application of heat.

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