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Trigeminal Neuralgia

Trigeminal neuralgia is a falls under the category of “facial pain” and is sometimes referred to as “atypical facial pain.”  The excruciating pain of trigeminal neuralgia originates in the trigeminal nerve. The trigeminal nerve is the fifth cranial nerve and is composed of three branches, the opthalmic, maxillary, and mandibular. Together they allow you to feel sensations on your face and control chewing. These three branches converge at the trigeminal ganglion (or nerve root) in your head. It is commonly believed that this unbearable condition is caused when a blood vessel becomes enlarged or lengthened and compresses this nerve root. [1]

The unfortunate patients who suffer this condition report periodic sharp, stabbing pain usually on one side of the face. It is relatively rare for Trigeminal Neuralgia to occur on both sides of the face and even rarer still for it to occur on both sides simultaneously.[2] Patients have described pain in the eyes, ears, lips, nose, and basically all areas of the face and scalp. Pain attacks can last from seconds to hours, generally with periods of remission in between. Patients are usually pain free between attacks, although some long-time sufferers report a dull-background throb at all times. [1]

At first look, trigeminal neuralgia is a relatively uncommon condition affecting only 1 in 15,000 to 20,000 people. However, these figures may be significantly higher as it is often misdiagnosed. [3] Correctly identifying Trigeminal Neuralgia early may significantly improve efficacy of treatment as it can be easier to reverse the neural pathways associated with the pain. The doctors at the Ainsworth Institute of Pain Management are experts in diagnosing trigeminal neuralgia and can offer you a combination of treatment options that are not available anywhere else.

What is Trigeminal Neuralgia?

Trigeminal Neuralgia Atypical Facial PainAs mentioned above, trigeminal neuralgia is thought to be a result of enlarged or aberrant blood vessels compressing the trigeminal nerve root. Over time, this compression can cause the nerve to function in an incorrect or erratic manor.

Short-term compression can often result in no symptoms whatsoever. Long-term and chronic compression of the ganglion and trigeminal branches can injure the nerve and cause it become hyperactive. In these cases the slightest stimulation, such as a breeze or a touch, can cause severe pain attacks in the affected area. What’s more, this sort of injury can stop the nerve’s ability to shut off pain after the stimulation ends, resulting in prolonged agony. [4]

Trigeminal Neuralgia affects 1 in 15,000 to 20,000 people (although the incidence may be much higher due to misdiagnosis). 15,000 new cases are reported in the US annually. It is more common in females than males, and symptoms generally appear after the age of 50. [5]

The Anatomy of the Trigeminal Nerve

Trigeminal neuralgia is the direct result of injury to the trigeminal nerve. In fact, advancing research increasingly implicates the entire trigeminal complex in almost all known facial pain. The trigeminal nerve is the 5th cranial nerve and it governs facial sensation and the muscles involved in mastication (chewing).

Like all cranial nerves the trigeminal nerve is paired and present on both sides of the body. The trigeminal nerve, however consists of three paired branches emanating from the nerve root. Hence the name “three-twins” (tri=three, geminal=twinned) The three Anatomy of Trigeminal Nervebranches are the opthalmic, the maxillary, and the mandibular. Each branch exits the skull through separate foramina (openings) and innervates different parts of the head.

Ophthalmic (V1)– Eyebrows, forehead, scalp, eye, upper eyelid.
Maxillary (V2) – Cheeks, lip, nostrils, lower eyelid, upper teeth
Mandibular (V3 – Lower teeth, lower lip, jaw and chin

Each branch can be responsible for transmitting pain. The ganglion (root where the 3 branches come together to enter the brain) can be responsible for perpetuating pain, and the whole trigeminal system itself can also be responsible for spreading pain to other nerves.

What are the Symptoms?

Patients suffering from trigeminal neuralgia can experience excruciating pain at the slightest stimuli, though some report pain episodes with no apparent trigger at all. [1] The pain typically is felt in any area on only one side of the face, implicating only one of the trigeminal nerve pair as the cause. Pain can occur on both sides of the face in some occasions. As mentioned above, the pain typically occurs in cycles with regular periods of remission. If untreated, the pain from trigeminal neuralgia can worsen over time. [6]

Patients have described the pain associated with trigeminal neuralgia in the following ways:

 Sharp, stabbing or shooting
  Electric shock-like sensations
  Burning, area of face on fire
 Sudden and unbearable “exploding” pain
 Crushing

Trigeminal Neuralgia frequently significantly interferes with a person’s ability to live their life as normal. Hygiene is impacted as patients cannot shave, wash their face or brush their teeth without severe pain. Some patients come to avoid situations or places they believe had something to do with triggering an episode. Out of fear, freedom can become restricted leading to depression and anxiety. [7]

What are the Causes?

Man talking with doctor with hand over mouthIt is thought that trigeminal neuralgia can be caused by a diverse variety of factors, some of which damage the myelin sheath that covers the trigeminal nerve. These can be:

 Result of aging
 Aneurysm (rare)
 Arteriovenous malformation
 Stroke
 Surgical injury
 Facial injury/trauma
 Multiple Sclerosis
 Postherpetic neuralgia (shingles)

What are my Treatment Options?

Trigeminal neuralgia is a difficult condition that is frequently misdiagnosed. Your doctor will have to perform a differential diagnosis in order to separate Trigeminal Neuralgia from other possible masticatory and temporomandibular conditions that might trigger pain because of movements of the mouth and facial muscles. [8] As always your doctor will need to ascertain your complete medical history and conduct a comprehensive physical examination.

Trigeminal Neuralgia has typically responded well to pharmacological interventions like antidepressants and anti-epileptics. These will generally be tried first before more interventional or surgical options.

Interventional Pain Management Treatments

Sphenopalatine Ganglion Block – The sphenopalatine ganglion is a small organ no bigger than a piece of corn that is buried inside the skull.  Amongst other things, it is responsible to conveying pain from the face into the brain.  By applying a small amount of local anesthetic onto it, one can effectively stop pain signals from reaching the brain.  If the block is successful, you doctor may recommend RFA to provide long lasting pain relief.  This procedure is quite effective for a variety of types of facial pain – meaning even if the exact diagnosis is unknown or just unclear, it can still work!

Gasserian Ganglion Block – The gasserian ganglion (better known as the trigeminal ganglion) is the meeting point for the 3 branches of the trigeminal nerve.  This ganglion has been implicated in a variety of facial pain syndromes as well as the dreaded Trigeminal Neuralgia.  Using X-ray imaging, local anesthetic is injected onto the ganglion, blocking it from sending pain signals to the brain.  In cases where the relief is only temporary, RFA may be the next step.

Stellate Ganglion Block – The stellate ganglion is an important part of the sympathetic nervous system and is well-known for its role in transmitting pain.  A small amount of a special long-acting local anesthetic called Bupivacaine is injected near the ganglion using Ultrasound-Guidance to stop the pain signals from reaching the brain.

Neurolysis & Ablation – In cases where an injection provides only temporary relief, neurolysis or neuroablation can be utilized to increase the duration. There are several different methods that can be used:

  • Radiofrequency Ablation (RFA) – Radio waves are applied to a nerve or plexus, preventing the transmission of pain.
  • Cryoablation – Similar to RFA, however cold temperatures are applied to the area instead of radio waves.
  • Chemodenervation – The premise is the same as cryoablation and RFA in that the goal is to prevent a nerve or plexus from transmitting pain; rather than applying mechanical stress to the nerve through radiowaves or cold temperatures, small amounts of either alcohol or phenol are injected to block the nerve’s ability to transmit a signal.

IV Infusion Therapy – An increasingly popular procedure for treating a variety of pain syndromes, as well as depression and anxiety. Patients are hooked up to an IV and special medications are administered intravenously. The infusions can take as little as 30 minutes to complete.

Spinal Cord Stimulation (SCS) – This is a commonly performed procedure for a variety of pain syndromes. SCS utilizes technology similar to that of cardiac pacemakers whereby small electrodes are placed into the epidural space near the spinal cord. These electrodes will produce a small electrical current over the spinal cord that interfere with pain signals. In the case of trigeminal neuralgia pain, the leads can placed in the at the top of the cervical spine where parts of the trigeminal nerve extend into the spinal cord.  Stimulation here can stimulate nerves from the back of the head as well as the face.

Peripheral Nerve Stimulation – The premise is similar to SCS but rather the leads are placed under the skin in the area of the pain. The leads are extremely thin and are totally unnoticeable.  Those suffering with facial pain, atypical facial pain, and most importantly – trigeminal neuralgia, 1 to 2 leads are placed under the skin along the branch of the trigeminal nerve(s) in the exact region of the pain from behind the hairline making it completely scarless.

The Ainsworth Institute is Here to Help

The doctors at the Ainsworth Institute of Pain Management specialize in the managing and treating Trigeminal Neuralgia. Dramatic improvements in pain and quality of life are a single phone call away. Schedule an appointment today with one of our board certified pain management experts to discuss what options for treatment may best suit your needs.

References

[1] Pope JE, Naurose S: Orofacial pain. In: Benzon HT, ed. Essentials of Pain Medicine. 3Rd ed. Philadelphia, PA: Saunders; 2011: 289-297.

[2] http://www.ncbi.nlm.nih.gov/pmc/ articles/PMC425870

[3] Rozen TD: Trigeminal neuralgia and glossopharyngeal neuralgia. Neurol Clin. 22:185-206 2004

[4] Singh N, Bharatha A, O’Kelly C, Wallace MC, Goldstein W, Willinsky RA, Aviv RI, Symons SP. Intrinsic arteriovenous malformation of the trigeminal nerve. Canadian Journal of Neurological Sciences. 2010 September; 37(5):681–683.

[5] Fleetwood IG, Innes AM, Hansen SR, et al.: Familial trigeminal neuralgia. Case report and review of literature. J Neurosurg. 95:513-517 2001

[6] Bayer DB, Stenger TG (1979). “Trigeminal neuralgia: an overview”. Oral Surg Oral Med Oral Pathol 48 (5): 393–9. doi:10.1016/0030-4220(79)90064-1. PMID 226915.

[7] www.ncbi.nlm.nih.gov/pubmed/24171179

[8] Drangsholt, M; Truelove, EL (2001). “Trigeminal neuralgia mistaken as temporomandibular disorder”. J Evid Base Dent Pract 1 (1): 41–50. doi:10.1067/med.2001.116846.

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