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Trigeminal Neuralgia
Trigeminal Neuralgia Treatment Symptoms and Diagnosis
What is Trigeminal Neuralgia?
General Information about Trigeminal Neuralgia
- The sharp facial pain of trigeminal neuralgia (also known as tic douloureux) usually arises from pressure on the trigeminal nerve caused by a blood vessel, usually the superior cerebellar artery.
- Other causes are tumor and multiple sclerosis, injury/damage to a nerve or lack of protective insulation of trigeminal nerve.
- About four in 100,000 people experience trigeminal neuralgia per year, and the condition is most common in males.
Symptoms
- Symptoms consist of intermittent shooting pain on one side of the face emanating from one or more branches of the trigeminal nerve.
- Symptoms, which last a few seconds, may be set off by chewing, swallowing, talking or other sensory stimulation the face.
Diagnosis
- Medical history and physical examination are key to diagnosing trigeminal neuralgia. The history should determine the following:
- An accurate description of pain localization to determine which divisions of trigeminal nerve are affected
- Determine the time of onset and what triggers the pain
- Determine what medications and dosages of medication have been tried
- Determine history of herpetic vesicles
- A magnetic resonance imaging (MRI) of the brain is used to rule out the possibility of tumor.
Treatment
- Medical therapy
- The first line of treatment is medication.
- The drug of choice is carbamazepine (TegretolTM), which eliminates or brings acceptable pain relief in 69 percent of patients.
- Baclofen (LioresalTM) is the second drug of choice and may be more effective if used with low-dose carbamazepine.
- Other medications that may be effective include pimozide, phenytoin (DilantinTM), capsaicin, clonazepam (KlonopinTM) and amitriptyline (ElavilTM).
- Surgical procedures
- Percutaneous trigeminal radiofrequency rhizotomy
- This procedure selectively destroys pain-causing nerve fibers while preserving touch fibers.
- Lesioning techniques include radiofrequency thermocoagulation, glycerol injection and mechanical trauma. They are used for patients who are poor candidates for major surgery.
- Complications can include weakness in chewing, facial numbness, changes in tearing or salivation and, less often, corneal ulcers, severe aching pain (anesthesia dolorosa) or meningitis.
- Microvascular decompression of the trigeminal nerve
- This surgical technique involves microsurgery to move the vessel, causing compression away from the trigeminal nerve.
- Relief is often long lived; however the incidence of facial numbness is much less than in selective rhizotomy and anesthesia dolorosa does not occur.
- The procedure is best for patients younger than 65 with no significant medical or surgical risk factors.
- Possible complications include asceptic meningitis, with head and neck stiffness; major neurological problems, including deafness and facial nerve dysfunction; mild sensory loss; cranial nerve palsy, causing double vision, facial weakness, hearing loss; and, on very rare occasions, postoperative bleeding and death.
- Microvascular decompression brings complete relief to 75 percent to 80 percent of patients. The recurrence rate is 5 percent to 17 percent.
- Glycerol injection
- This treatment is similar to that for radiofrequency rhizotomy. A needle is inserted in the region of the trigeminal ganglion, and glycerol (a colorless fatty liquid used in many food and skin products) is deposited nearby.
- Results of this procedure are less predictable because after the glycerol is injected its location cannot be controlled precisely.
- Although 80 percent of patients treated with glycerol initially experience respite from trigeminal neuralgia, more than half of these experience a return of the pain within five years after surgery.
- A small degree of numbness in the area of the pain remains after the procedure.
- Balloon compression
- This treatment is based on older treatments for trigeminal neuralgia consisting of massage or partial injury of the trigeminal nerve.
- A small balloon is passed through a catheter (narrow tube) into the skull to the location of the trigeminal ganglion. There it is inflated, and compression causes partial injury to the trigeminal ganglion.
- Pain is no longer transmitted to the brain, so the trigeminal neuralgia is, in effect, blocked.
- Because this procedure is new, results are less known and few surgeons are using this method.
- Stereotactic radiosurgery
- The treatment involves focusing radiation on the trigeminal nerve. The radiation will cause injury to the nerve preventing it from transmitting the pain.
- There are different machines available to perform this procedure, including Gamma Knife, X-Knife, Cyberknife and Novalis. UCLA uses Novalis. This machine is able to shape the beam to the shape of the target.
- The success of this procedure is 90 percent to 95 percent with few side effects.
