Posted by: Thixia | March 26, 2008

Trigeminal Neuralgia (TN)

What is it?

TN is an extremely severe facial pain that tends to come and go unpredictably in sudden shock-like attacks.  The pain is often described as stabbing, shooting, excruciating, burning, extremely strong.  The pain usually lasts for a few seconds, but there can be many bursts of pain in quick succession.  It is a chronic disorder of the trigeminal nerve (or 5th cranial nerve).

The Trigeminal Nerve has 3 branches (or divisions):

  1. The upper 1st branch (Ophthalmic) which runs above the eye, forehead, and front of the head.
  2. The middle 2nd branch (Maxillary) which runs through the cheek, upper jaw, teeth and gum, side of the nose.
  3. The lower 3rd branch (Mandibular) which runs through the lower jaw, teeth, and gums.

TN can involve one or more branches.  Most frequently, the middle and lower branches are affected.  It usually affects people over 50 years old, but many cases have been reported in young adults, and very rarely among children.  It affects women more than men, and it is more often on the right side of the face.  It is not hereditary.

                                                                                          

What are the causes of TN?

This is still an area of discordance among the medical professionals.  Most of them believe that the deterioration of the myelin (protective coating of the nerve) allows the transmission of abnormal messages of pain.  The damage of the myelin sheath may be caused by pressure from blood vessels or arteries, tumours, Multiple Sclerosis, injury to the nerve, consequences of shingles, or just aging process.

                                                                                          

Diagnosis

If after several visits to a dentist, a GP or an Ear-Nose-Throat specialist, TN is suspected the patient is sent to a neurologist.  He/she will perform some neurological tests to rule out or discover other diseases. He will also ask you for a precise description of the pain.  Most doctors will recommend a MRI scan in order to see if there is any obvious cause for the pain.

                                                                                          

Classical TN

Spasms of sharp, stabbing pain, often described as like a jolt of lightning.  The pain is confined in the area served by the branches of the TN nerve: lower jaw, upper jaw, cheek, eye, and forehead.  The pain may include one, two or the three branches of the TN nerve.  Pain is almost always on one side of the face, most commonly the right hand side.   The pain is usually provoked by a light touch on the face, movements of the face (and therefore mouth), touching the side of the nose, a light breeze.  Trigger points are usually around the nose and lip.  The pain might disappear by itself for weeks, even months, and return.

Bonnie’s Note:

One of my symptoms is TN.  Suddenly a jagged bolt of lightening tracks across my right cheek, starting at my temple and ending near my mouth.  And then another follows that one.  It is agony.  Thank goodness this is not a constant symptoms, about once a year for a few days, as my medication usually controls TN.

                                                                                          

Atypical TN

Aching, burning pain, mainly in the cheek, upper jaw and sometimes lower jaw.  It is less likely to happen in the eye and forehead area.  A trigger point is more difficult to define than in typical TN.  Sometimes, after a long period, classical TN can also be accompanied with atypical TN.  This leads to a combination of the sharp, electric shock like pain plus the dull aching pain.

                                                                                          

What Medical Treatment is Available?

There are various medical and surgical treatments for TN.  The usual process is to start with medications, most commonly anticonvulsant, originally developed to treat epilepsy.  Patients need to understand that these medications do not work like painkillers: you need to maintain a therapeutic level of medication in your blood for effective relief of the pain.  Regular blood tests are needed, in order to check the medication level in your blood.  Taking the medication irregularly is not effective.  To avoid severe side effects, the medication is increased or decreased slowly, according to your doctor’s advice.  After the patient is pain free for about 3 to 6 weeks, the medication is then slowly tapered. Abrupt withdrawal can lead to serious side effects.  Always maintain a good communication with your doctor when you are under a medical treatment; it will allow him to find the right treatment and the right dose you need to stop the severe attacks of pain.

Most commonly used anticonvulsants are:

  • Tegretol (carbamazepine)
  • Phenytoin (Dilantin)
  • Neurontin (Gabapentin) and
  • Baclofen (Lioresal).

Treatment can also include antidepressants such as Amitriptyline.

                                                                                          

What Surgical Options Are There?

When medications are not working, or when severe side effects are unacceptable, surgery is considered.  You will need to be referred to a neurosurgeon with experience in TN.  Surgical procedures vary from nerve blocks through the cheek, open skull surgery or radiation.  It is a difficult decision to make, and it is your referring doctor and neurosurgeon’s duty to inform you on all procedures available.  Simple surgical procedures are used to damage the TN nerve, in order to block the electrical activity transmitting the pain.  They involve passing a needle through the cheek under local anaesthesia.  Then, the nerve can be: bathed in glycerol (Glycerol injection), frozen (cryotherapy), heated (thermocoagulation or radiofrequency rhizotomy), or compressed with a small balloon (balloon compression).  Those procedures leave a feeling of numbness in the face.  The average period of relief varies from a few months to a few years.  They can be repeated easily.

The other option is Microvascular Decompression (MVD: An opening is made behind the ear, and the surgeon moves away all blood vessels or arteries compressing the nerve.  It requires a general anaesthesia, and a minimum stay of one week in hospital.  Numbness in the face is extremely rare.  95% of patients have immediate relief after an MVD, about 75% are still pain free 5 years later.

Gamma Knife is a fairly new procedure involving radiation beams targeted with high precision to the base of the nerve.  Although the first results are promising, there is no long-term study on the success rate, and there are only three hospitals carrying this procedure in the UK.  But it has many advantages for the patient, as it is mostly pain free and non-invasive.  The usual process when you have TN is to try medications.  Then, if pain persists or returns, you can consider having surgery.  MVD is generally recommended to younger and healthy patients, because this is their best chance for a long-term relief.  Peripheral procedures are recommended for elderly or frail patients, or for those who do not want to take the risks associated with a major surgery but would accept a feeling of numbness in the face.  Having surgery is an important decision to make, and it should be discussed with an experienced neurosurgeon, who can explain all possible side effects and consequences of the operation.  There is no procedure that is 100% sure to be effective.  It is therefore important to receive clear and complete information before making a decision.                                                                 

                                                                                          

Any information or advice given on this site is meant for guidance purposes only and you are responsible for determining whether such information or advice applies to your particular ailment or disorder. The information and advice should not be relied upon as statements or representations of facts. Although the TNA UK is trying its best to help you, no warranty is given as to the accuracy of the information given. Any information given on this site is not meant to be comprehensive and you should always seek expert advice and assistance from your own medical adviser. Any information, advice and manuals provided should be followed and or read carefully at all times. All information contained on this site is provided without responsibility on the part of The Trigeminal Neuralgia Association of the United Kingdom (hereafter to be known as TNA UK) or any contributing person or organisation and to the full extent permissible by law. TNA UK accepts no liability for any loss, damage or injury arising as a result of any reliance on the service, advice and information set out on the site or arising in connection with Trigeminal Neuralgia or any other ailments, illnesses, or disabilities. This site has been put together to comply with English Law and is hosted by the United Kingdom. All visits to the site shall be governed by English Law absolutely.                 

                                                                                              

This information is from:

Trigeminal Neuralgia Association United Kingdom

http://www.tna.org.uk/index.php

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Responses

  1. Excellent article. T hank you.
    I will add it to my site and give you and your site, full credit.
    Contact me please, when yo get opportunity:

  2. Thank you. I appreciate your comment and the fact that you have added me to your site.

    Bonnie

  3. Hi Scamparoo,

    I found your blog post via a search on Google for Trigeminal Neuralgia. My friend Ben and I started a patient to patient support group called LivingWithTN (www.livingwithtn.org) for people with Trigeminal Neuralgia. Check it out. We started it a month ago and already have 50+ people providing support to each other on it. You can share your experiences and draw support from the folks there. Great little community.
    cheers,
    Scott

  4. I have had these attacks for over 6 years.This time they are lasting longer – over months – last week stopped for a few days then back again. I had a mri – and while I was having it I had constant small electrical shocks but nothing showed up that would cause this pain. any suggestions.

  5. That is so disappointing when that happens. Was your MRI a full body MRI or just of your brain. Sometimes the lesions are on the spine, not on the brain.

    The attacks that I get do not show up on the MRI either.


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