TRIGEMINAL NEURALGIA

Trigeminal neuralgia (TN), or Tic Douloureux, ( also known as prosopalgia ) is a neuropathic disorder of the trigeminal nerve that causes episodes of intense pain in the eyes, lips, nose, scalp, forehead, and jaw. Trigeminal neuralgia is considered by many to be among the most painful of conditions and is often labeled the "suicide disease" because of the significant numbers of people taking their own lives when they cannot find effective treatments. An estimated 1 in 15,000 people suffers from trigeminal neuralgia, although numbers may be significantly higher due to frequent misdiagnosis. It usually develops after the age of 40, although there have been cases with patients being as young as three years of age.

The episodes of pain occur paroxysmally, or suddenly. To describe the pain sensation, patients describe a trigger area on the face, so sensitive that touching or even air currents can trigger an episode of pain. It affects lifestyle as it can be triggered by common activities in a patient's daily life, such as toothbrushing. Breezes, whether cold or warm, wintry weather or even light touching such as a kiss can set off an attack. The attacks are said to feel like stabbing electric shocks or shooting pain that becomes intractable. Individual attacks affect one side of the face at a time, last several seconds or longer, and repeats up to hundreds of times throughout the day. The pain also tends to occur in cycles with complete remissions lasting months or even years. 3-5% of cases are bilateral, or occurring on both sides. This normally indicates problems with both trigeminal nerves since one serves strictly the left side of the face and the other serves the right side. Pain attacks typically worsen in frequency or severity over time. A great deal of patients develop the pain in one branch, then over years the pain will travel through the other nerve branches.

Signs of this can be seen in males who may deliberately miss an area of their face when shaving, in order to avoid triggering an episode. Although trigeminal neuralgia is not fatal, successive recurrences may be incapacitating, and the fear of provoking an attack may make sufferers reluctant to engage in normal activities.

There is a variant of trigeminal neuralgia called "atypical trigeminal neuralgia". In some cases of atypical trigeminal neuralgia, the sufferer experiences a severe, relentless underlying pain similar to a migraine in addition to the stabbing pains. This variant is sometimes called "trigeminal neuralgia, type 2", based on a recent classification of facial pain. In other cases, the pain is stabbing and intense, but may feel like burning or prickling, rather than a shock. Sometimes, the pain is a combination of shock-like sensations, migraine-like pain, and burning or prickling pain. It can also feel as if a boring piercing pain is unrelenting.

There is no cure for trigeminal neuralgia, but most people find relief from medication, from one of the five surgical options or sometimes from one of the many so-called "complementary or alternative" therapies. Atypical trigeminal neuralgia, which involves a more constant and burning pain, is more difficult to treat, both with medications and surgery. Surgery may result in varying degrees of numbness to the patient and lead rarely to "anesthesia dolorosa," which is numbness with intense pain. However, many people do find dramatic relief with minimal side effects from the various surgeries that are now available. During a TN attack, some patients may get quick relief by applying an ice pack or a readily available source of cold temperature to the area of pain

Surgery may be recommended, either to relieve the pressure on the nerve or to selectively damage it in such a way as to disrupt pain signals from getting through to the brain. In trained hands, surgical success rates have been reported at better than 90 percent.

Surgery may be recommended, either to relieve the pressure on the nerve or to selectively damage it in such a way as to disrupt pain from getting through to the brain. In trained hands, surgical success rates have been reported at better than 90 percent.

Of the five surgical options, the microvascular decompression is the only one aimed at fixing the presumed cause of the pain. In this procedure, the surgeon enters the skull through a 25mm (one-inch) hole behind the ear. The nerve is then explored for an offending blood vessel, and when one is found, the vessel and nerve are separated or "decompressed" with a small pad. When successful, MVD procedures can give permanent pain relief with little to no facial numbness.

Three other procedures use needles or catheters that enter through the face into the opening where the nerve first splits into its three divisions. Excellent success rates using a percutaneous surgical procedure known as balloon compression have been reported. This technique has been helpful in treating the elderly for whom surgery may not be an option due to coexisting health conditions. Balloon compression is also the a good choice for patients who have ophthalmic nerve pain or have experienced recurrent pain after microvascular decompression.

Similar success rates have been reported with glycerol injections and radiofrequency rhizotomies. Glycerol injections involve injecting an alcohol-like substance into the cavern that bathes the nerve near its junction. This liquid can mildly injure the nerve enough to hinder the errant pain signals. In a radiofrequency rhizotomy, the surgeon uses an electrode to heat the selected division or divisions of the nerve. Done well, this procedure can target the exact regions of the errant pain triggers and disable them with minimal numbness.

The nerve can also be damaged to prevent pain signal transmission using Gamma Knife or a linear accelerator-based radiation therapy (e.g. Novalis, Cyberknife). No incisions are involved in this procedure. It uses radiation to bombard the nerve root, this time targeting the selective damage at the same point where vessel compressions are often found. This option is used especially for those people who are medically unfit for a long general anaesthetic, or who are taking medications for prevention of blood clotting (e.g., warfarin). A prospective Phase I trial performed at Marseille, France, showed that 83% of patients were pain-free at 12 months, with 58% pain-free and off all medications. Side effects were mild, with 6% experiencing mild tingling and 4% experiencing mild numbness.

TREATMENTS

Dr Michael H. Brisman and Dr. Brown specialize in trigeminal neuralgia. Together, they are able to offer the full range of medical and surgical accepted options for the treatment of complex facial pain syndromes including trigeminal neuralgia.

See Treatments for more information

INTERACTIVE VIDEO

Microvascular Decompression for Trigeminal Neuralgia