Living with Trigeminal Neuralgia

Trigeminal neuralgia is a rare chronic pain condition that affects about 12 people in every 100,000. If you are unfortunate enough to live with this condition, then you know the extreme pain that is usually associated with trigeminal neuralgia. Although many trigeminal neuralgia cases are caused by impingement of the trigeminal nerve by a local blood vessel, in many other cases, the trigeminal nerve may dysfunction causing very intense pain without an identifiable cause. There are treatment options for trigeminal neuralgia ranging from surgical procedures to medications.

A Closer Look at Trigeminal Neuralgia

In the United States, less than 1 percent of the population suffers from trigeminal neuralgia, but trigeminal neuralgia patients constitute about 14 percent of all patients with neuropathic pain. However, some experts believe that this estimate may be low because so many trigeminal neuralgia cases are misdiagnosed as dental pain or other pain conditions. The majority of trigeminal neuralgia cases occur in women usually in middle or late middle age, although TN has been known to strike men and children.

The trigeminal nerve is the primary nerve to the face with three branches that extend to the eyes, jaw and mouth. When trigeminal neuralgia initially develops, there is usually a pain in the maxillary nerve branch which innervates the nose, upper lip and upper teeth, or the mandibular nerve branch which innervates the lower lip, lower cheek and jaw. Trigeminal neuralgia may occur on both sides of the face, but it more commonly affects just the right side.

Trigeminal neuralgia occurs when the trigeminal nerve is damaged. There are two types of trigeminal neuralgia: classical and symptomatic.  Classical trigeminal neuralgia is more common and seemingly has no cause, while symptomatic trigeminal neuralgia may arise from other conditions like cancer, aneurysm, meningitis, multiple sclerosis or Lyme disease.

Although classical trigeminal neuralgia has no visible trigger, most experts believe that the condition is attributable to a blood vessel pressing on the trigeminal nerve. This prolonged pressure strips the nerve of its protective myelin sheath. Once bereft of this insulation, the trigeminal nerve may fire in response to almost any sensation. However, many people experience trigeminal neuralgia without any evidence of nerve impingement by blood vessels.

Trigeminal neuralgia is characterized by episodes of intense pain that may last up to two hours. There may be extended periods where no attacks occur, but this condition may still worsen over time, so ongoing treatment is advised. Over time, these periods free of pain may shorten and become less frequent.

Diagnosing Trigeminal Neuralgia

It may be difficult to get your trigeminal neuralgia correctly diagnosed because many doctors see so few TN cases and may mistake it for some other pain condition. If you believe you have trigeminal neuralgia, it may be necessary to visit a pain specialist.

Your doctor should begin the diagnostic process with a physical evaluation that should identify the key features of this condition which include

  • Type of pain—the pain is very intense, sudden and brief
  • Localized to the face—the doctor should identify the facial regions where the pain occurs and correlate it to the trigeminal nerve
  • Triggers—common sensations like a light breeze, talking or eating may cause an episode

If the signs point to trigeminal neuralgia, your physician may perform a tactile and reflex test in which she will touch various areas of your face and observe your reactions. An MRI scan involving an injected dye to highlight blood vessels may also be used to determine if a blood vessel is pressing against the trigeminal nerve.

Treatments for Trigeminal Neuralgia

Upon diagnosis for trigeminal neuralgia, your doctor should immediately begin a course of treatments, starting with more conservative ones first.

  • Anticonvulsant medications—many patients with trigeminal neuralgia respond positively to anticonvulsant drugs like carbamazepine but there may be side effects including nausea, dizziness, drowsiness or confusion. Over time, the efficacy of the drug you are on may decline, at which point, your physician may increase the dosage or switch to another drug.
  • Antispasmodic agents—drugs like baclofen can help some patients with trigeminal neuralgia. These drugs may be used alongside carbamazepine or on its own.
  • Botox—several smaller studies have shown that botulinum toxin injections may help people who have developed a resistance to medications. The evidence is not definitive and more research is needed.

If these therapies are not effective, then you may need a surgical procedure.

  • Microvascular decompression—your surgeon will relocate or remove the blood vessels that are pressing on the trigeminal nerve.  After making an incision behind the ear and drilling into the skull, your surgeon will move the problematic blood vessels or place a soft cushion between it and the nerve. If no impingement is found, then part of the trigeminal nerve may be cut.
  • Brain stereotactic radiosurgery—this procedure involves irradiating the root of the trigeminal nerve. This will, in effect, prevent the nerve from functioning and may cause loss of sensation in the face.
  • Glycerol injection—the physician will insert a needle into the base of your skull where the trigeminal cistern is located. A tiny amount of glycerol will then be injected into this small sac of spinal fluid surrounding trigeminal nerve ganglion. The glycerol will damage the nerve and should numb the pain.
  • Balloon compression—after inserting a needle into the base of the skull, the surgeon will insert a balloon next to the trigeminal nerve and inflate enough to damage it and block pain signals. There is usually at least a short period of facial numbness.
  • Radiofrequency thermal lesioning—this procedure will destroy the nerve fibers that are producing the pain. A hollow needle is inserted near where the trigeminal nerve passes through the base of the skull. An electrode is then inserted through the needle and applies heat to the nerve which damages it and creates a lesion. Your physician may create additional lesions if the first is unsuccessful in mitigating the pain. Numbness typically lasts from 3 to 4 years.

Article written by: Dr. Robert Moghim – CEO/Founder Colorado Pain Care

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