Trigeminal
neuralgia (TN), or Tic Douloureux, ( also known as
prosopalgia ) is a neuropathic disorder of the trigeminal
nerve that causes episodes of intense pain in the
eyes, lips, nose, scalp, forehead, and jaw. Trigeminal
neuralgia is considered by many to be among the most
painful of conditions and is often labeled the "suicide
disease" because of the significant numbers of
people taking their own lives when they cannot find
effective treatments. An estimated 1 in 15,000 people
suffers from trigeminal neuralgia, although numbers
may be significantly higher due to frequent misdiagnosis.
It usually develops after the age of 40, although
there have been cases with patients being as young
as three years of age.
The episodes of pain occur paroxysmally, or suddenly.
To describe the pain sensation, patients describe
a trigger area on the face, so sensitive that touching
or even air currents can trigger an episode of pain.
It affects lifestyle as it can be triggered by common
activities in a patient's daily life, such as toothbrushing.
Breezes, whether cold or warm, wintry weather or even
light touching such as a kiss can set off an attack.
The attacks are said to feel like stabbing electric
shocks or shooting pain that becomes intractable.
Individual attacks affect one side of the face at
a time, last several seconds or longer, and repeats
up to hundreds of times throughout the day. The pain
also tends to occur in cycles with complete remissions
lasting months or even years. 3-5% of cases are bilateral,
or occurring on both sides. This normally indicates
problems with both trigeminal nerves since one serves
strictly the left side of the face and the other serves
the right side. Pain attacks typically worsen in frequency
or severity over time. A great deal of patients develop
the pain in one branch, then over years the pain will
travel through the other nerve branches.
Signs of this can be seen in males who may deliberately
miss an area of their face when shaving, in order
to avoid triggering an episode. Although trigeminal
neuralgia is not fatal, successive recurrences may
be incapacitating, and the fear of provoking an attack
may make sufferers reluctant to engage in normal activities.
There is a variant of trigeminal neuralgia called
"atypical trigeminal neuralgia". In some
cases of atypical trigeminal neuralgia, the sufferer
experiences a severe, relentless underlying pain similar
to a migraine in addition to the stabbing pains. This
variant is sometimes called "trigeminal neuralgia,
type 2", based on a recent classification of
facial pain. In other cases, the pain is stabbing
and intense, but may feel like burning or prickling,
rather than a shock. Sometimes, the pain is a combination
of shock-like sensations, migraine-like pain, and
burning or prickling pain. It can also feel as if
a boring piercing pain is unrelenting.
There is no cure for trigeminal neuralgia, but most
people find relief from medication, from one of the
five surgical options or sometimes from one of the
many so-called "complementary or alternative"
therapies. Atypical trigeminal neuralgia, which involves
a more constant and burning pain, is more difficult
to treat, both with medications and surgery. Surgery
may result in varying degrees of numbness to the patient
and lead occasionally to "anesthesia dolorosa,"
which is numbness with intense pain. However, many
people do find dramatic relief with minimal side effects
from the various surgeries that are now available.
During a TN attack, some patients may get quick relief
by applying an ice pack or a readily available source
of cold temperature to the area of pain
Surgery may be recommended, either to relieve the
pressure on the nerve or to selectively damage it
in such a way as to disrupt pain signals from getting
through to the brain. In trained hands, surgical success
rates have been reported at better than 90 percent.
Surgery may be recommended, either to relieve the
pressure on the nerve or to selectively damage it
in such a way as to disrupt pain signals from getting
through to the brain. In trained hands, surgical success
rates have been reported at better than 90 percent.
Of the five surgical options, the microvascular decompression
is the only one aimed at fixing the presumed cause
of the pain. In this procedure, the surgeon enters
the skull through a 25mm (one-inch) hole behind the
ear. The nerve is then explored for an offending blood
vessel, and when one is found, the vessel and nerve
are separated or "decompressed" with a small
pad. When successful, MVD procedures can give permanent
pain relief with little to no facial numbness.
Three other procedures use needles or catheters that
enter through the face into the opening where the
nerve first splits into its three divisions. Excellent
success rates using a cost effective percutaneous
surgical procedure known as balloon compression have
been reported. This technique has been helpful in
treating the elderly for whom surgery may not be an
option due to coexisting health conditions. Balloon
compression is also the best choice for patients who
have ophthalmic nerve pain or have experienced recurrent
pain after microvascular decompression.
Similar success rates have been reported with glycerol
injections and radiofrequency rhizotomies. Glycerol
injections involve injecting an alcohol-like substance
into the cavern that bathes the nerve near its junction.
This liquid is corrosive to the nerve fibers and can
mildly injure the nerve enough to hinder the errant
pain signals. In a radiofrequency rhizotomy, the surgeon
uses an electrode to heat the selected division or
divisions of the nerve. Done well, this procedure
can target the exact regions of the errant pain triggers
and disable them with minimal numbness.
The nerve can also be damaged to prevent pain signal
transmission using Gamma Knife or a linear accelerator-based
radiation therapy (e.g. Novalis, Cyberknife). No incisions
are involved in this procedure. It uses radiation
to bombard the nerve root, this time targeting the
selective damage at the same point where vessel compressions
are often found. This option is used especially for
those people who are medically unfit for a long general
anaesthetic, or who are taking medications for prevention
of blood clotting (e.g., warfarin). A prospective
Phase I trial performed at Marseille, France, showed
that 83% of patients were pain-free at 12 months,
with 58% pain-free and off all medications. Side effects
were mild, with 6% experiencing mild tingling and
4% experiencing mild numbness.
TREATMENTS
Dr Michael
H. Brisman and Dr. Brown specialize in trigeminal neuralgia.
Together, they are able to offer the full range of medical
and surgical accepted options for the treatment of complex
facial pain syndromes including trigeminal neuralgia.
Trigeminal
neuralgia (TN), or Tic Douloureux, ( also known as
prosopalgia ) is a neuropathic disorder of the trigeminal
nerve that causes episodes of intense pain in the
eyes, lips, nose, scalp, forehead, and jaw. Trigeminal
neuralgia is considered by many to be among the most
painful of conditions and is often labeled the "suicide
disease" because of the significant numbers of
people taking their own lives when they cannot find
effective treatments. An estimated 1 in 15,000 people
suffers from trigeminal neuralgia, although numbers
may be significantly higher due to frequent misdiagnosis.
It usually develops after the age of 40, although
there have been cases with patients being as young
as three years of age.