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How to Treat Trigeminal Neuralgia?


Trigeminal neuralgia is a neuralgia (nerve pain) involving the trigeminal nerve, which is responsible for facial sensation and motor functions such as biting and chewing. It usually produces a sharp, stabbing, and burning pain of the face. It is also called tic douloureux, which means painful tic, named by French physician Nicholas Andre in 1756.

Where is the location of the pain from trigeminal neuralgia?

Trigeminal neuralgia pain occurs at the face, mouth, lips, teeth, or nose. Even though there are two trigeminal nerves, one on each side, the pain is usually unilateral, meaning it affects one side.

The trigeminal nerve has three branches, including the ophthalmic, maxillary, and mandibular; however, trigeminal neuralgia symptoms usually involve the maxillary and mandibular branches.

What kind of pain is produced by trigeminal neuralgia?

In trigeminal neuralgia, the pain can vary but is usually sharp, stabbing, and burning. At first, the attacks can be brief, with mild pain, but as the disease progresses, the attacks typically become longer and are more severe.

Is trigeminal neuralgia a fatal disease?

Even though trigeminal neuralgia and its complications do not cause mortality (death), the symptoms can cause significant morbidity, which is suffering from a disease or medical condition.

Who is at a risk for trigeminal neuralgia?

Usually, it is people over 50, and women more often than men in a 3:2 ratio. The annual incidence of trigeminal neuralgia is about 15 for every 100,000 people.

Are there different types of trigeminal neuralgia?

There are three main classes of trigeminal neuralgia based on the etiology (cause).

  1. Classical trigeminal neuralgia is one of the more common etiologies, occurring when a blood vessel (artery or vein) presses on the trigeminal nerve and disrupts its function.
  2. Secondary trigeminal neuralgia occurs when there is some other type of neurological disorder, such as multiple sclerosis or a brain tumor.
  3. Idiopathic trigeminal neuralgia occurs when the etiology is unknown.

How is the trigeminal neuralgia diagnosis made?

Your physician or medical provider must first diagnose the condition and cause before initiating any treatment. The diagnosis is made by a focused neurological exam and either a computed tomography (CT or CAT) scan or magnetic resonance imaging (MRI) scan. Note the MRI is more sensitive and specific than the CT scan.

The MRI, and sometimes the CT scan, can detect an abnormality at the nerve root, including neurovascular compression (a nerve compressed from a blood vessel) or the presence of a tumor. In addition, the MRI allows visualization of the entire nerve and to see if there is any issue like loss of its myelin sheath (the insulating outer layer of the nerve), as seen in multiple sclerosis (MS).

What are the non-surgical treatments for trigeminal neuralgia?

Medication, like carbamazepine (Tegretol), is the first line treatment for trigeminal neuralgia. It is started at a lower dose and eventually increased to a maintenance dose of 400 – 800 mg/day, in divided doses.

While carbamazepine is the generic form, Tegretol is one of the common brand names. If you’ve heard that name before, it’s because carbamazepine (Tegretol) is also used to treat seizures and bipolar disorder.

Other medications can be used for trigeminal neuralgia, including lamotrigine (Lamictal), clonazepam, phenytoin (Dilantin), topiramate, gabapentin (Neurontin), sodium valproate, and others. Some people need a combination of medications to reduce or eliminate symptoms.

Injections, also called nerve blocks are a good alternative for those whose symptoms do not respond to medications and are unwilling to undergo surgery. Lidocaine (a type of anesthetic) or similar derivatives can be helpful for nerve block purposes.

After several years of unsuccessful medication trials and nerve blocks, surgery is usually recommended.

What are the surgical treatments for trigeminal neuralgia?

A rhizotomy is a surgical procedure done by a surgeon under general anesthesia in the operating room. It involves the surgeon inserting a needle through the facial cheeks and directly touching the trigeminal nerve fibers. When the needle touches the nerve fibers, it can "deaden" the nerve using an electrical current (heat), chemicals, or balloon compression.

In microvascular decompression surgery, the surgeon makes an incision behind the ear to access the trigeminal nerve, then places a Teflon (synthetic polymer) cushion between the trigeminal nerve and the blood vessel, hence the word "decompression."

Gamma Knife treatment, also known as CyberKnife or stereotactic surgery, involves placing a precise radioactive beam onto the trigeminal nerve. This procedure is painless, takes about 45 minutes, and can be done as an outpatient.

References:

Brown, J. A., C. Coursaget, M. C. Preul, and D. Sangvai, 'Mercury Water and Cauterizing Stones: Nicolas André and Tic Douloureux,' Journal of Neurosurgery, 90.5 (1999), 977–81 <https://doi.org/10.3171/jns.1999.90.5.0977>

Antonaci, F., S. Arceri, M. Rakusa, D. D. Mitsikostas, I. Milanov, V. Todorov, and others, ‘Pitfalls in Recognition and Management of Trigeminal Neuralgia’, The Journal of Headache and Pain, 21.1 (2020), 82 <https://doi.org/10.1186/s10194-020-01149-8>

‘Trigeminal Neuralgia - Symptoms and Causes’, Mayo Clinic <https://www.mayoclinic.org/diseases-conditions/trigeminal-neuralgia/symptoms-causes/syc-20353344> [accessed 17 August 2022]

Yadav, Yad Ram, Yadav Nishtha, Pande Sonjjay, Parihar Vijay, Ratre Shailendra, and Khare Yatin, ‘Trigeminal Neuralgia’, Asian Journal of Neurosurgery, 12.4 (2017), 585–97 <https://doi.org/10.4103/ajns.AJNS_67_14>

‘Trigeminal Neuralgia’, 2021 <https://www.hopkinsmedicine.org/health/conditions-and-diseases/trigeminal-neuralgia> [accessed 18 August 2022]

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