Trigeminal Neuralgia

Definition Trigeminal neuralgia is sudden, severe facial nerve pain. The pain in the face has been described as stabbing, piercing or like an electric shock. The pain can last from just a few seconds to two minutes each time. In most cases it only affects one side of the face (unilateral), more commonly the right side. Rarely, people with trigeminal neuralgia have pain on both sides of their face (bilateral). In !"#!$ of cases the pain is caused by pressure on the trigeminal nerve, the largest nerve inside the skull.

Types of trigeminal neuralgia Trigeminal neuralgia can be split into different categories depending on the type of pain. These are described below. Trigeminal neuralgia type % (T&%) is the classic form of trigeminal neuralgia. The piercing and stabbing pain only happens at certain times and is not constant. This type of neuralgia is known as idiopathic (when no cause can be identified) Trigeminal neuralgia type ' (T&') can be referred to as atypical (not typical) trigeminal neuralgia. (ain is more constant and involves aching, throbbing and burning sensations )ymptomatic trigeminal neuralgia ()T&) is when pain results from an underlying cause, such as multiple sclerosis

Who is affected? Trigeminal neuralgia is rare. In the *+, it affects four or five people out of every %!!,!!! each year. ,lmost twice as many women are affected as men. The condition becomes more common with age and is rare in people under -! years of age. Trigeminal neuralgia is most commonly seen in people between .! to /! years of age. Symptoms of trigeminal neuralgia

The main symptom of trigeminal neuralgia is a severe stabbing or piercing pain in your face that comes on suddenly. The pain is almost always on one side of your face, although in rare cases it is on both sides. It can be in the lower jaw, upper jaw, cheek, and less often the eye and forehead. The pain may last from a few seconds to two minutes each time and you may also feel0

tingling or numbness in your face before the pain develops a slight ache or burning feeling during the attack

1ou may have spasms of pain regularly for days, weeks or months at a time. In severe cases, you may feel pain hundreds of times a day. )ome people e2perience a constant dull ache in certain areas between episodes of pain. 3owever, it is possible for pain to disappear completely and not reoccur for months or years. Triggers of trigeminal neuralgia 4pisodes of trigeminal neuralgia can be triggered by certain actions or movements, such as0

talking smiling chewing brushing your teeth a light touch shaving swallowing a cool bree5e head movements

6iving with trigeminal neuralgia can be difficult, and it can interfere with your 7uality of life. 1ou may feel like avoiding activities such as washing, shaving or eating in order to avoid triggering pain. 6iving with pain, especially if it affects your 7uality of life, can also lead to depression (feelings of e2treme sadness or despair that last a long time). Atypical trigeminal neuralgia

,typical means irregular or not typical. If you have this type of trigeminal neuralgia, you will feel prolonged pain between attacks. It may be a constant throbbing, aching or burning sensation. This form of trigeminal neuralgia responds less well to treatment than classic trigeminal neuralgia. Causes of trigeminal neuralgia Although the e act cause is not al!ays "no!n, trigeminal neuralgia is often caused by compression of the trigeminal nerve or an underlying disease. The trigeminal nerve The trigeminal nerve (also called the fifth cranial nerve) is the largest nerve inside the skull. 1ou have two trigeminal nerves, one in each side of your face. 4ach nerve splits into three branches0 the upper branch (ophthalmic) 8 supplies the skin above the eye, forehead and front of the head the middle branch (ma2illary) 8 supplies the skin through the cheek, side of the nose, upper jaw, teeth and gums the lower branch (mandibular) 8 supplies the skin through the lower jaw, teeth and gums 9etween them, these three branches transmit sensations of pain and touch from your face, teeth and mouth to your brain. Trigeminal neuralgia can involve one or more branches of the trigeminal nerve. The ma2illary branch is affected most often and the ophthalmic branch is least affected. #ressure on the trigeminal nerve 4vidence suggests that in !"#!$ of cases, the cause of trigeminal neuralgia is pressure on the trigeminal nerve close to where it enters the brain stem (the lowest part of the brain that merges with the spinal cord). :ne study found that in .-$ of cases, the cause of the pressure on the trigeminal nerve was an artery, and in ;.$ of cases it was caused by a vein. It is thought pressure on the trigeminal nerve causes uncontrollable pain signals to travel along the nerve to your face, resulting in the sudden stabbing pains. $ther underlying causes :ther underlying causes that can affect the trigeminal nerve include0

a tumour (a growth or lump) a cyst

multiple sclerosis, a long"term condition that affects the central nervous system (the brain and spinal cord) In multiple sclerosis, nerve fibres of your central nervous system become damaged by the immune system (the body<s defence system). This damage can affect the trigeminal nerve.

Triggers &euralgia can sometimes be triggered or made worse by a number of different things. 1ou may be able to ease the pain of neuralgia by avoiding these triggers as much as possible. =or e2ample, your pain may be triggered by wind or even a draught in a room. If this is the case, avoid sitting near open windows or the source of air conditioning, and wear a scarf wrapped around your face in windy weather. 3ot or cold food, or drink may trigger your pain, so try to avoid anything very hot or icy cold. *sing a straw to drink warm or cold drinks may help prevent the li7uid coming in contact with the painful areas of your mouth.

Treatment for trigeminal neuralgia Trigeminal neuralgia is a chronic (long"term) condition that often gets worse over time. There is currently no cure. 6iving with trigeminal neuralgia can be difficult and can interfere with a person>s 7uality of life. 3owever, medication usually provides temporary relief. If medication is not effective or causes unpleasant side effects, surgery may be recommended. The aim of surgery is to either stop your blood vessels putting pressure on the trigeminal nerve, or to damage the nerve just enough to stop the pain signals. Research suggests that surgery provides effective long"term pain relief and that around /!"#!$ of people are unlikely to e2perience recurring pain. 3owever, the chance of the pain returning will vary depending on the type of surgery used. There are also potential side effects to consider before having surgery, such as hearing loss or facial numbness. 1ou should discuss this with the specialist in charge of your care before deciding which treatment to have. Treating trigeminal neuralgia Complementary therapies

)ome people find using complementary therapies alongside regular treatment can them help to manage pain. ?omplementary therapies include0 meditation and other rela2ation techni7ues massage acupuncture vitamin therapy 3owever, there is currently no clinical evidence for the effectiveness of these treatments. %edication can provide temporary relief from the pain of trigeminal neuralgia. Surgery may be considered for people !ho e perience severe pain despite medication, !orsening pain or adverse effects from the medication. 1our @( will first prescribe a type of medicine called an anticonvulsant (usually used to treat sei5ures in epilepsy), which can help relieve pain in your face. These drugs work by slowing down electrical impulses in the nerve and reducing its ability to transmit pain. &ormal painkillers such as paracetamol are not effective in treating trigeminal neuralgia. The anticonvulsant medicine called carbama5epine (see below) is usually the first medication recommended. 3owever, if carbama5epine is not effective, a different anticonvulsant called gabapentin may be used. Carbama&epine ,lthough carbama5epine is usually used to treat epilepsy, it can sometimes be effective in treating trigeminal neuralgia because it lessens the uncontrollable pain signals. 1ou will usually need to take this medicine one to two times a day to begin with, although some people may need a higher dose. ?arbama5epine can cause side effects which may make it difficult for some people, such as the elderly, to use. (ossible side effects are outlined below. 'ery common side effects These side effects have affected more than one in %! people and include0

nausea (feeling sick) and vomiting di55iness tiredness finding it difficult to control movements

a reduced number of infection"fighting white blood cells (leukopenia) changes in liver en5yme levels (en5ymes are proteins that speed up any reaction happening in the body)

(eferral to a specialist ,nticonvulsants for trigeminal neuralgia may stop working over time. This is because they are only effective in numbing the pain and not at stopping the cause of it. If this occurs, you may be referred for specialist treatment. 1ou may also be referred for specialist treatment for trigeminal neuralgia if0

you have pain in your face between spasms of trigeminal neuralgia any of your senses are affected anticonvulsants are not effective in controlling your pain anticonvulsants cause you to e2perience severe side effects you are under -! years old you don>t want to take medication for the indefinite future

)pecialist treatment may be provided by a number of different healthcare specialists including0 a neurologist 8 a specialist in conditions of the central nervous system who will test to rule out multiple sclerosis, and advise on medication

a pain specialist in treating trigeminal neuralgia who can prescribe medication

a neurosurgeon 8 an e2pert in surgery of the brain and nervous system who may advise whether surgery is likely to be beneficial If carbama5epine or gabapentin have not been effective in controlling your pain, your specialist may recommend other medications. =or e2ample, o2carba5epine and phenytoin may be recommended for treating trigeminal neuralgia, although they may currently be unlicensed for treating this condition in the *+.

#ossible procedures )ome procedures that you may wish to consider are outlined briefly below, although they each carry risks.

glycerol in)ection 8 this is injected into the central part of the trigeminal nerve to provide temporary pain relief for around ."%' months peripheral radiofre*uency thermocoagulation 8 electrical stimulation is used to damage the nerve endings but carries a risk of permanent untreatable pain (anaesthesia dolorosa) balloon compression 8 a tiny balloon is inflated over the trigeminal nerve to relieve pressure. This may be used in rare cases if surgery has been unsuccessful electric current 8 this is used to numb the trigeminal nerve and can be very effective Research has shown #!$ of people will gain immediate pain relief from radiofre7uency thermocoagulation, glycerol injection or balloon compression. 3owever, A!$ of patients will lose sensation in their face after the procedure. (atients having peripheral radiofre7uency thermocoagulation may find their pain returns after one year.

Surgery )urgery may be recommended. The aim of surgery is to either stop your blood vessels from putting pressure on the trigeminal nerve, or to damage the nerve just enough to stop the uncontrollable pain signals. The two surgical procedures used are0

microvascular decompression ablative treatments

These are described below. %icrovascular decompression Bicrovascular decompression is an operation to release the pressure of blood vessels pressing on the trigeminal nerve. Curing microvascular decompression surgery, the surgeon will either remove or relocate the blood vessels, separating them from the trigeminal nerve. =or most people, this type of surgery is effective in easing the pain of trigeminal neuralgia and appears to provide the longest lasting relief. In over /!$ of people, pain relief was still felt %! years after surgery. 3owever, the operation can cause hearing loss which is estimated to occur in less than ;$ of people. ,lso, it is possible for pain to return after surgery and for surgery to cause a loss of sensation in the face, but this is unusual and often

temporary. Dery rarely, this type of surgery can result in stroke, meningitis or even death. Stereotactic radiosurgery )tereotactic radiosurgery is a fairly new treatment that uses a concentrated beam of radiation to try and reduce pain signals travelling along the trigeminal nerve. )tereotactic radiosurgery does not re7uire anaesthetic (painkilling medication) and no incisions (cuts) are made in your skin. 1our surgeon will discuss with you e2actly what is involved before your operation. )o far, this treatment has been found to be 7uite effective for trigeminal neuralgia0 ;;"#!$ of patients e2perience an immediate end to facial pain, although %-$ of patients can e2pect to have pain returning after % months. The treatment can take up to two months to achieve its ma2imum effect. )tereotactic radiosurgery can cause facial numbness in $ of cases. *ncommon complications include0

loss of taste numbness in the eyes deafness

This procedure, although safe, is generally not recommended unless there are e2ceptional reasons not to use other techni7ues.