Trigeminal neuralgia

Trigeminal neuralgia is a condition that causes very severe recurrent pain in some areas of the face.

Anatomy: The trigeminal nerve is the fifth paired cranial nerve and is divided into three branches:
• eye branch (forehead, temples, eyes and scalp), • maxillary branch (upper jaw, cheeks, outer nose, upper lip, palate, upper teeth and gums),

• mandibular branch (lower lip, lower gums, lower arch and tongue margin).

This nerve receives the sensitive signals of the superficial and deeper regions of the face and innervates the masticatory muscles.

Anyone suffering from trigeminal neuralgia can experience excruciating pain with even slight stimulation of the face, such as brushing teeth or make-up.
Initially, only brief and mild attacks may occur, but trigeminal neuralgia may progress, producing longer and more frequent bouts of burning pain.
This condition affects women more often than men.

Usually people over 50 years of age are affected, very rarely it is children and adolescents.
Neuralgia means pain coming from the nerve.
These complaints rarely occur bilaterally, they almost always affect only one side of the face.


Types of trigeminal neuralgia

1. Patients with type 1 trigeminal neuralgia report symptoms as “very severe pain that comes on suddenly.”
The pain has only a duration of a few seconds each time and can occur several times a day.
Even if the attacks become more frequent, the pain always comes suddenly and is never constant.
Although the attacks can often occur spontaneously, patients with type 1 trigeminal neuralgia show triggering factors such as cold wind, eating, drinking or drying the face.
In addition, patients with trigeminal neuralgia type 1 may observe a spontaneous subsidence of symptoms that lasts for days or weeks.
These pain-free periods are getting shorter and shorter and show up less and less over time.

2. A less common form of the complaint is called atypical trigeminal neuralgia (type 2).
This variant may have some characteristics of type 1 trigeminal neuralgia (such as sudden and very severe pain), but also other symptoms: constant pain and burning.
Patients with trigeminal neuralgia type 2 experience a much more insidious onset of pain.
Instead of feeling a pain blow that occurs suddenly, they think they have a toothache or sinusitis for months before the pain diagnosis is made by a neurologist.
As with trigeminal neuralgia type 1, the symptoms are extremely debilitating.
The prognosis after surgery for atypical trigeminal neuralgia is less favorable than in patients suffering from trigeminal neuralgia type 1.

Symptoms of trigeminal neuralgia

  • Inflammation of the trigeminal nerve causes sudden pain coming from one or more branches of the trigeminal nerve. The pain is usually very severe.
    The second and third branches are most commonly affected. Therefore, the headache is usually localized in the area of the cheeks, jaw or both.
    The first branch is less affected, the pain above the forehead and around the eyes occurs less often.
  • The pain is like an electric shock, penetrating, cutting or similar to a knife stabbing.
    It usually lasts a few seconds, but can also last up to two minutes. The pain can occur so suddenly and violently that the patient jumps up or grimaces in pain.
    Minutes, hours or days can pass between pain impulses.
  • Sometimes the pain repeats itself in rapid succession.
    After an attack, one may feel a dull pain and numbness over the affected area, which subside in a short time.
    The pain points are often on the nose and mouth.

However, persistent facial pain is not yet a characteristic of trigeminal neuralgia.
Also, tinnitus or ringing in the ears are not caused by this neuralgia.
The pain can be triggered by touching some points on the face or by drafts.
Rarely, symptoms appear at night.

That’s why some people refrain from brushing their teeth or shaving so as not to trigger a pain attack.
Eating, talking, smoking, brushing your teeth or swallowing can cause pain.
Some people report pain on the plane. These can be caused by cold (usually the air in it is cooler).
Apart from the pain attacks, there are usually no other symptoms, the nerve functions normally and the examination by a doctor would not reveal any abnormalities.

Causes of trigeminal neuralgia (or inflammation of the trigeminal nerve)

About 9 out of 10 cases are caused by pressure of a blood vessel on the root of the nerve, where it exits from the brain into the skull. However, it is not known why a blood vessel presses on the trigeminal nerve in adults or the elderly.
It is believed that the cause is an aneurysm, i.e. a blood vessel found in one place that causes the pressure.
In rare cases, trigeminal neuralgia is the symptom of another condition.
For example, it can develop due to a tumor, multiple sclerosis, or an abnormality at the base of the skull. In some cases, the cause is unknown.

Which specialist should I contact? Diagnosis of trigeminal neuralgia

The doctor in charge is the neurologist who diagnoses trigeminal neuralgia on the basis of the symptoms and excluding other diseases, especially since there is no specific examination to detect this disorder.

Other diseases that are excluded by differential diagnosis include:
• Multiple sclerosis
• Post-herpetic neuralgia (after having a herpes zoster) • Sinusitis (sinusitis) • Cluster headache (also causes lacrimation) • Horton’s arteritis (or temporalis) • Dental disease (for example, gum shrinkage or post-extractive alveolitis)
• Tumor pressing
on the nerve • Temporomandibular joint problems

The most appropriate device examination is magnetic resonance imaging, which shows whether a blood vessel or tumor mass is pressing on the nerve.

Treatment of trigeminal neuralgia

Treatment of trigeminal neuralgia usually begins with medication, and many people do not need other treatments.
However, over time, some people with this condition may no longer respond to the medication or experience side effects.
For these patients, other treatment options include injection therapy or surgery.
If this disorder is caused by another condition, such as multiple sclerosis, the doctor must treat the underlying disease.

Medications for trigeminal neuralgia

To treat trigeminal neuralgia, the doctor usually prescribes drugs that reduce or turn off pain signals to the brain.
During pregnancy, you should talk to your doctor before taking any medication.

Doctors generally prescribe carbamazepine for trigeminal neuralgia, which has been shown to be effective in treating this condition.
Oxcarbazepine (Trileptal) is an anticonvulsant that may be used to treat trigeminal neuralgia.
Other medications may be useful, including clonazepam (Rivotril), pregablin (Lyrica), and gabapentin (Neurontin).

Muscle relaxant medications such as baclofen (Lioresal) can be taken alone or in combination with carbamazepine. Side effects include: confusion, nausea and drowsiness.
Corticosteroids Doctors often prescribe cortisone-containing medications
for the pain. The benefits are of little importance, and there are many side effects.

Surgery for trigeminal neuralgia

The aim of the surgery is to interrupt the pressure on the trigeminal nerve caused by a blood vessel, or to trancut the nerve to prevent the transmission of pain signals to the brain.
The operation is performed under general anesthesia, the surgeon opens the skull through a hole (called a craniotomy) and this requires a one- or two-day hospital stay.

  • Microvascular decompression (MVD) is a surgical procedure in which the blood vessel is carefully moved and pressure on the nerve is reduced.
    A few centimeters large opening of the skull behind the ear is called a craniotomy.
    This opening exposes the trigeminal nerve and its connections with the brainstem. A blood vessel (rarely a tumor) can compress the nerve. After freeing the nerve, a small Teflon sponge is inserted to separate the blood vessel from the nerve. The sponge stays in the brain forever.
    Microvascular decompression surgery provides immediate relief in 95% of patients. In 20% of cases, a pain relapse occurs within 10 years. The main advantage of MVD is that it usually does not cause facial numbness. The main disadvantages are the risks of anesthesia and that of interfering with the brain.
  • Rhizotomy – is the irreversible transection of the trigeminal root and its connections to the brainstem. The surgeon makes a small incision at the back of the skull. A stimulation probe is used to identify the motor nerve root. The main motor root, which supplies the masticatory muscles, must be preserved. The sensory fibers that transmit pain signals to the brain are severed. Transection of the nerve causes permanent numbness of the face and should only be considered for recurrent pain that has not responded to other treatments.

Outpatient percutaneous surgery for trigeminal neuralgia

The percutaneous procedures are minimally invasive techniques to reach the trigeminal nerve through the face without a skin incision or opening of the skull. A hollow needle is inserted through the skin (percutaneously) of the cheek, at the base of the skull, into the trigeminal nerve. The aim of the procedure of rhizotomy or injection is to damage an area of the trigeminal nerve in order to interrupt the sending of pain signals to the brain.
Usually, these procedures are performed on an outpatient basis under local anesthesia and mild sedation.
Patients return home the same day.

  • Radiofrequency rhizotomy (PSR) uses heat to selectively destroy some fibers of the trigeminal nerve that cause pain. After anesthesia, a hollow needle and electrode are inserted through the cheek and nerve. The patient is awakened and weak current is passed through the electrode into the nerve for stimulation. According to the patient’s instructions, the surgeon positions the electrode so that the tingling occurs in the area of pain attacks. If the area causing the pain is located, the patient is anesthetized again and the doctor can now send heating current through the electrode, which only destroys this nerve section.
    PSR provides immediate pain relief in 98% of patients. About 20% of patients experience a recurrence of pain within 15 years. Complications can be: double vision, jaw weakness, loss of corneal reflex, chewing difficulties, sensory disturbances or partial numbness in the facial areas where the pain previously occurred.
  • The glycerin injection is similar to the PSR, in that a hollow needle is inserted through the cheek into the nerve.
    The needle is positioned in the cisterna trigeminalis (an area containing fluid in the ganglion).
    Glycerin is injected into the cistern to destroy the fibers of the trigeminal nerve that cause the pain. Since it is not possible to determine exactly in which area the glycerol goes, the results are quite unpredictable. The injection of glycerin provides immediate relief in 70% of patients. About 50% of patients report a pain recurrence within 3-4 years. As with PSR, partial numbness of the face is possible and the complications are similar.
  • Compression with a balloon is similar to a PSR, in that a hollow needle is inserted over the cheek to the nerve. This procedure is performed under general anesthesia. The surgeon inserts a balloon into the trigeminal nerve via a catheter. At the level of the fibers that cause the pain, the balloon is inflated. The balloon presses on the nerve and destroys the fibers that cause the pain. After a few minutes, the balloon and catheter are removed again.
    Balloon compression leads to immediate pain relief in 80% of patients. About 20% of patients report a recurrence within 3 years. Complications may include mild numbness, chewing problems, or double vision.

Neurectomy can be performed on the branches of the nerve, which are exposed through a small incision.
Transection of the supraorbital nerve (trigeminal nerve V – 1) may be recommended for isolated pain above the forehead.
Transection of the infraorbital nerve (branch V-2) is performed for pain limited to the area below the eye along the cheekbone.
The transection of the nerve leads to a complete loss of sensitivity of the facial area innervated by the trigeminal nerve.

Radiosurgery for trigeminal neuralgia

The aim of this radiation treatment is to damage the root of the trigeminal nerve in order to interrupt the pain signals transmitted to the brain.
Stereotactic radiotherapy is a noninvasive outpatient procedure in which beams of radiation are used to destroy some fibers of the trigeminal nerve.
A stereotactic mask or frame is fixed to the patient’s head for precise localization of the nerve after resonance magnetic images, so that the head is kept completely still during treatment.

The highly concentrated beams are directed at the root of the trigeminal nerve.
In the weeks following treatment, a lesion (injury) gradually develops in the place where the rays hit.
An improvement in pain does not occur immediately, but gradually over time. About 50% of patients experience pain relief within 4 weeks; 75% of patients improve within 8 weeks.
Patients continue to take pain relief medication for a period of time after treatment, while radiation takes effect.
70% of patients are relieved of their pain for 2 years.
In about 50% of patients, the pain recurs after 3 to 5 years after treatment.
Complications consist of numbness of the face and dry eyes.

Natural remedies and treatments for trigeminal neuralgia

Acupuncture In trigeminal neuralgia, acupuncture
is an important pain and anti-inflammatory therapy. In addition, it has no side effects like medication.
The benefits of this therapy are not only limited to pain relief, but also serve muscle relaxation and anti-inflammation.
In some patients who are sensitive to this therapy, the doses of the medication decrease, as do the symptoms.

Since some cervical nerves are related to the trigeminal nerve, the brain can “err” and confuse neck pain with facial pain. Therefore, it is recommended to treat the neck with osteopathy for pain relief.

ice can temporarily relieve pain because it numbs the nerve, but this is not therapy.

Nutrition and diet for trigeminal neuralgia

Nerves need vitamins for their health, especially thiamine (vitamin B1).
It is recommended to get this substance through a healthy vegan diet, rather than through supplements made in the laboratory.

How long does the disease last? Prognosis

Usually, this disorder is protracted and does not pass without treatment.

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