Trigeminal Neuralgia
Ronald Brisman, M.D.
 

Trigeminal Neuralgia

 

Introduction:

  • Trigeminal Neuralgia is an uncommon condition associated with agonizing face pain that makes it difficult to talk or eat. Additional extreme discomfort may be associated with the fear that such pain may recur, often at unpredictable moments.
  • Much can be done to help patients who suffer from Trigeminal Neuralgia.
  • The best over-all medical care for patients with Trigeminal Neuralgia requires expertise in diagnosis, imaging (MRI scan), treatment with medicines and neurosurgical operations: Gamma Knife radiosurgery (GKRS), needle rhizotomies (radiofrequency electrocoagulation [RFE], glycerol and balloon micro-compression) and microvascular decompression (MVD).
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 What are the symptoms associated with Trigeminal Neuralgia?

  • Pains are brief, lasting from seconds to a couple of minutes. Attacks of repeated brief bursts of severe pain may occur and last for an hour or more.
  • Pains are usually shooting, stabbing, sharp and electric-like.
  • Pains are usually triggered by light touch such as talking, eating or brushing the teeth.
  • Pains are located in the face, usually in the cheek, lips, jaw, palate, tongue, teeth, gums, side of the nose and, less often, about the eye and forehead.
  • Pain is usually on one side of the face, although infrequently, similar pains may develop at some other time on the other side of the face.
  • Pains usually respond, at least initially, to carbamazepine (Tegretol) or oxcarbazepine (Trileptal).
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 What are the parts (divisions) of the Trigeminal Nerve?

There are three parts (divisions) of the TRIgeminal nerve. The first supplies feeling to the eye, forehead and bridge of the nose. The second supplies feeling to the upper lip, palate, upper teeth, gums, mid and inner cheek below the eye and front of the nose. The third provides sensation to the jaw, lower teeth, gums, lower lip and side of the tongue. Pain may involve any of these locations but usually involves the second or third divisions, either alone or in combination. Trigeminal neuralgia may involve the first division but usually in association with the second division. Pain in only the first division is often not trigeminal neuralgia. 

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 What causes Trigeminal Neuralgia?

The trigeminal nerve carries messages regarding sensation from the face to the brain. Patients with Trigeminal Neuralgia have a defect in the covering of the trigeminal nerve, which allows abnormal cross-talking between nerves that usually carry messages of normal non-painful sensation with nerves that carry painful messages. This defect in the covering of the nerve is often caused by a blood vessel that presses on the nerve close to where it leaves the brain. Occasionally, multiple sclerosis is the culprit. Infrequently, a brain tumor can cause Trigeminal Neuralgia. Sometimes, the exact cause cannot be determined.

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 Is Trigeminal Neuralgia inherited?

Not usually. But in about 5 percent of patients, there is another family member who has Trigeminal Neuralgia. If you have Trigeminal Neuralgia, most likely your children or grandchildren will not develop it.

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 How do you diagnose Trigeminal Neuralgia?

  • The most important diagnostic maneuver is to have a consultation with a physician who is experienced in the diagnosis and treatment of trigeminal neuralgia. He will listen very carefully to you and will perform an office examination. He will discuss treatment options.
  • MRI is helpful for diagnosing a brain tumor or multiple sclerosis. A special thin-section MRI (one mm thick slices) without and with dye injected into the vein will show the relationship between any blood vessels and the trigeminal nerve.
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 How do you treat Trigeminal Neuralgia?

There are always three options for patients with Trigeminal Neuralgia: no treatment (sometimes the pains subside on their own), medicines or neurosurgical procedures.

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 What medicines are helpful for patients with Trigeminal Neuralgia?

  • Most of the medicines that are helpful for treating Trigeminal Neuralgia are anti-seizure medicines, even though Trigeminal Neuralgia is not a seizure and is not epilepsy.
  • The most effective are carbamazepine (Tegretol) and oxcarbazepine (Trileptal). Also helpful are gabapentin (Neurontin), pregabalin (Lyrica) and lamotrigine (Lamictal).
  • Baclofen (Lioresal) is a muscle relaxer and not an anti-seizure medicine and it has also sometimes been helpful for patients with Trigeminal Neuralgia.
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 Who is a candidate for a neurosurgical procedure?

A neurosurgical procedure is recommended for those who are bothered by either pain or side-effects of medicines.

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 What are the neurosurgical procedures to treat Trigeminal Neuralgia?

  • Gamma Knife Radiosurgery (GKRS) [least invasive]
  • Needle rhizotomy (Radiofrequency, glycerol or balloon microcompression) [a little more invasive]
  • Microvascular decompression (MVD) [most invasive]
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 What is Gamma Knife Radiosurgery (GKRS)?

This is a minimally invasive procedure that is done as an out-patient and requires a few hours in the hospital facility. The trigeminal nerve is treated with highly focused radiation (that does not affect other parts of the body). Special equipment (the Gamma Knife is the gold standard for such focused radiation treatment) includes a computer driven system that provides extremely precise delivery of radiation to the trigeminal nerve. Although many patients may obtain pain relief within the first two weeks of Gamma Knife Radiosurgery, most take about 4 to 6 weeks to get relief. A few get facial numbness, which is not usually bothersome. Recurrent pain may occasionally occur but can be treated by either a repeat Gamma Knife Radiosurgery or another procedure.

» Continued...

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 What is Needle Rhizotomy?

This is an out-patient procedure that requires a few hours in the hospital facility and is a little more invasive than the GKRS. During needle rhizotomy, a specially designed needle is inserted through the cheek under x-ray control, and directed towards the trigeminal nerve close to where it enters the brain. The nerve is treated with either heat (Radiofrequency Electrocoagulation), a chemical (glycerol) or balloon microcompression. As balloon microcompression requires a bigger needle and has more complications than RFE or glycerol, I (Ronald Brisman, M.D.) usually favor needle rhizotomy with either RFE or glycerol. Facial numbness, although not usually bothersome, is more likely after needle rhizotomy than GKRS. Most patients get pain relief from needle rhizotomy. Recurrence may occasionally occur but can be treated by either a repeat needle rhizotomy or another procedure.

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 What is Microvascular Decompression (MVD)?

This is the most invasive neurosurgical procedure for trigeminal neuralgia. It is a formal operation. The patient is admitted to the hospital and usually will stay for 2 or 3 days. General anesthesia is used and the patient is put to sleep for the operation. A cut is made in back of the ear, some bone is removed, the dura (covering of the brain is cut), the brain is gently moved out of the way, the trigeminal nerve is seen as well as any blood vessel impinging on it. The surgeon places some synthetic material (shredded Teflon felt) to separate the blood vessel from the nerve. Most patients get pain relief. Recurrence may occasionally develop but can be relieved by another procedure, usually a Gamma Knife radiosurgery or needle rhizotomy. Although the operation can usually be done safely, occasionally there are complications, which infrequently can be severe.

» Continued...

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 What is the Minimally Invasive Alternative?

Many patients with medically intractable trigeminal neuralgia (those who are bothered by pain or side-effects of medicines) can be managed with minimally invasive techniques (either Gamma Knife radiosurgery or needle rhizotomy with RFE and/or glycerol). These can be repeated if necessary for recurrent pain that is not satisfactorily managed with medicines.

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