What is Trigeminal Neuralgia?
Trigeminal neuralgia, also called tic douloureux, is a severely painful condition that affects the face and/or mouth in the distribution of one or more divisions of the trigeminal nerve. The trigeminal nerve has three divisions:
ophthalmic/V1
maxillary/V2, and
mandibular/V3.
In trigeminal neuralgia the maxillary and mandibular divisions are more likely to be affected. The pain typically affects one side of the face or mouth, and rarely, both sides. Most patients with trigeminal neuralgia are over 50 years old.
What are the Symptoms of Trigeminal Neuralgia?
Patients typically describe their pain as a severe, sharp-shooting, electric-shock-like pain, rated as a 10 out of 10 that lasts a few seconds to 2 minutes and occurs multiple times during the day.
The pain is triggered by stimuli that would not normally cause pain. Some examples of pain triggers include:
brushing teeth
washing face
make-up application
shaving
touching a tooth
eating and drinking
smiling
talking
playing a musical instrument such as a flute, trumpet, or recorder
breeze on the face
The pain involves areas that are innervated by the trigeminal nerve, which include the cheeks, lips, jaws, teeth, gingivae (gum), and less frequently the areas around the eyes and forehead supplied by the ophthalmic division (V1).
Approximately 50% of patients have a trigger spot or zone, which when touched triggers their pain. Some patients may experience remission periods: days to years during which little or no pain occurs.
In addition to the severe attacks of pain, some patients may experience continuous pain between attacks, which may be aching, throbbing, or burning in character.
What Causes Trigeminal Neuralgia?
Classical trigeminal neuralgia is caused by compression of the trigeminal nerve by an overlying blood vessel. This leads to deformation of the nerve resulting in alteration of the conduction of nerve impulses to the sites supplied by the nerve - the face, and mouth.
Secondary trigeminal neuralgia results when the painful symptoms are caused by other conditions that affect the trigeminal nerve such as multiple sclerosis or invasive brain tumors that trap the nerve against adjacent structures.
In idiopathic trigeminal neuralgia, no identifiable cause for the symptoms is detected.
How is Trigeminal Neuralgia Diagnosed?
The diagnosis is based on a detailed clinical history and examination. The clinical history will include multiple questions about the location, quality, duration, frequency of the pain. Aggravating and alleviating factors that influence the pain will also be noted.
The clinical examination will include a general head and neck examination, cranial nerve evaluation, musculoskeletal evaluation, and dental examination.
An MRI/MRA of the brain is typically recommended to verify trigeminal nerve compression by an artery and to rule out other disorders that can present with features similar to trigeminal neuralgia such as a brain tumor or multiple sclerosis.
How is Trigeminal Neuralgia Treated?
Medications: Treatment is initiated with anticonvulsant medications that are used for neuropathic pain conditions.
Other treatment modalities for patients who fail medication therapy include rhizotomy, gamma knife radiosurgery, and surgery. All treatment modalities have advantages and disadvantages, therefore, each patient's symptoms, medical conditions, age, and personal choices are considered in the decision process.
Rhizotomy is a minimally invasive surgical procedure in which the trigeminal nerve ganglion or root is destroyed using various modalities such as thermal, chemical (glycerol), or balloon compression. The main disadvantage of this procedure is that permanent and sometimes disabling facial numbness may occur as a complication.
Gamma knife radiosurgery or stereotactic radiosurgery involves using a precise dose of gamma radiation to ablate the trigeminal nerve root. It is not considered an invasive procedure; therefore, it can be performed on patients with advanced medical conditions who cannot tolerate microvascular decompression.
Microvascular decompression is an invasive surgical procedure performed by neurosurgeons to separate the artery (typically the superior cerebellar artery), compressing the trigeminal nerve, thereby relieving pressure from the nerve, resulting in symptom relief and a high rate of success for most patients.
© 2023. What is Trigeminal Neuralgia? Dr. Chizobam Idahosa.
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