Trigeminal Neuralgia

About Trigeminal Neuralgia

What You Should Know 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 quality of the pain
  • Determine the time of onset and what triggers the pain
  • Determine what medications and dosages of medication have been tried
  • Determine if there are any red flags that suggest a diagnosis other than trigeminal neuralgia
• A magnetic resonance imaging (MRI) of the brain is used to evaluate for other causes of pain, such as a tumor or multiple sclerosis.

Treatment

• The first line of treatment is medication.
• First line medical therapy include oxcarbazepine (Trileptal) and carbamazepine (Tegretol™), which eliminates or brings acceptable pain relief in 69 percent of patients.
• Other medications that may be effective include baclofen, pimozide, phenytoin (Dilantin™), capsaicin, clonazepam (Klonopin™) and amitriptyline (Elavil™).

Meet Our Experts Who Treat Trigeminal Neuralgia

Surgical procedures

• 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 is rare.
  • 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 90 percent to 95 percent of patients. The recurrence rate is up to 15 percent within 2 years after the surgery.
• 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.
  • This procedure is often associated with some loss of sensation in the face on the side that is treated, with a small risk of anesthesia dolorosa.
  • This procedure is successful in approximately 85-90% of patients, with pain recurrence in 20-30% of patients within 2 years.
• Percutaneous trigeminal radiofrequency rhizotomy
  • This procedure selectively destroys pain-causing nerve fibers while preserving touch fibers.
  • This is used for patients who are in urgent need for surgical interventions, with focal facial pain, or who are poor candidates for major surgery.
  • This procedure requires the patient to be awakened during the procedure to accurately localize the treatment.
  • 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.
  • This procedure is successful in approximately 75-85% of patients, with pain recurrence in 20-30% of patients within 2 years.
• 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.
  • It is best for patients with pain in the V3 distribution, radiating into the lower lip or chin.
  • 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.
• 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 70 percent to 75 percent and usually takes 4-6 weeks to be effective. Up to 1/3 of patients still require some medications after treatment. Few side effects are expected.