Trigeminal Neuralgia

Trigeminal Neuralgia is a specific type of facial pain resultant from compression or irritation to the trigeminal nerve. It is characterised by sharp, lancinating sensations on one side of the face only. These will last a few seconds at a time, and are often associated with a dull ache between them. Episodes can be triggered by mundane activities such as washing the face, brushing teeth, applying make-up, smiling, kissing, talking, eating or even simply touching the face.

What is the Trigeminal Nerve?

The largest of the twelve cranial nerves, the trigeminal nerve is responsible for supplying sensations to the face and mucous membranes, as well as motor functions such as biting or chewing. Each trigeminal nerve exits the pons in the brain via a large sensory root and a separate smaller motor root coming out of the pons (a structure located in the brain stem whose function is to help relay messages from the cortex and the cerebellum) – where it extends into the face, dividing into three major branches:

  • the ophthalmic nerve (responsible for sensory functions)
  • the maxillary nerve (responsible for sensory functions)
  • the mandibular nerve (responsible for sensory and motor functions)

Symptoms

Trigeminal neuralgia has been described as excruciatingly painful by patients, to the point that during episodes a sufferer may not be able to think of anything else aside from the symptoms, or complete any type of task, however simple.

As previously noted, the disorder usually only affects one side of the face although in some extremely rare cases, it can affect both. Severe sharp stabbing pains may be felt in the lower or upper jaw, the cheek, the teeth and although less commonly, in the forehead or eye.

Causes

The most likely cause of the disorder is compression or irritation of the trigeminal nerve caused by an encroaching blood vessel, resulting in painful symptoms in some, but not in others. One possible explanation for this, may be the blood vessel coming into contact with the nerve at a particularly sensitive point –  or it may be a result of wear to the nerve’s myelin sheath – an insulating layer.

Other possible causes may include a tumour, cyst or another type of lesion.

Diagnosis

A detailed medical examination with specific attention to the patient’s description of the pain and its location will be required. The condition may initially be mistaken for a dental complaint such as a tooth infection, it may also be confused with migraine, joint pain, temporal arteritis or associated with multiple sclerosis.

Following a suspected diagnosis further investigation with an MRI or CT scan of the brain will be needed to be able to detect if a blood vessel is compressing one of the trigeminal nerves.

Treatment

Medication

Medication is with specific anticonvulsant drugs used in the treatment of nerve pain and, uniquely, carbamazepine or oxcarbazepine medication. In some cases medication is sufficient to stop the painful symptoms.

Percutaneous Procedures

This describes a procedure whereby inner tissue or organs are accessed via a needle puncture, rather than open surgery. In the case of trigeminal neuralgia, a needle is inserted through the cheek and into the trigeminal nerve inside the skull. Different procedures may include:

  • radiofrequency lesioning
  • balloon compression
  • glycerol injections

By causing deliberate damage to the trigeminal nerve, these procedures are thought to relieve pain by disrupting the pain signals sent by the nerve.

Surgery

If there is a firm diagnosis that the compression or irritation of the trigeminal nerve is caused by a blood vessel, then a surgical opinion is helpful, as it can be curative. Microvascular decompression is a form of surgery carried out under general anaesthetic –  the surgeon makes an incision into the skull, removing a small piece of bone, having located the trigeminal nerve and identified the offending vessel, the surgeon then separates the blood vessel from the nerve, either by constructing a sling made from adjoining tissue, or by placing a small piece of teflon sponge between the nerve and the blood vessel, allowing the nerve to heal. In some cases the blood vessel may be adhered to the nerve, in which case it may be cauterised and relocated.

Microvascular decompression is not usually a first line of treatment due to the associated risks of general surgery and more specifically to craniotomy – however, if other forms of treatment have proven ineffective, it may be considered and in many cases can be curative.

Complications

Although trigeminal neuralgia is a very painful condition, it is not fatal and tends to occur in episodes. It does however, seriously affect quality of life and many patients may avoid a number of every day activities such as washing, eating, shaving etc. for fear of triggering an attack – this brings with it a significant emotional strain which may lead to depression or anxiety.

Pain Management Clinic

Consisting of a multi-disciplinary team of physicians, surgeons, psychologists, physiotherapists and other health professionals, the pain management clinic will provide a comprehensive treatment plan, addressing all aspects of the conditions and any possible side effects as a result, helping patients cope with and manage their symptoms.

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