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Trigeminal Neuralgia

(Tic Doleureux)

Definition

Trigeminal neuralgia (TN) is a disorder of the trigeminal nerve (fifth cranial nerve) that causes severe, shooting pain along one side of the face. The trigeminal nerve senses touch, pain, pressure, and temperature. It also helps make saliva and tears.
The Trigeminal Nerve
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In TN, pain usually lasts for less than a second to a few seconds and may come and go for days, weeks, months, or years. It may go into remission or stop completely for months or years. Over time, though, the attacks may become more frequent and more severe. Attacks can be brought on by chewing, washing, shaving, touching, or even a breeze on the face.

Causes

In most cases, the cause is unknown. In some cases an abnormally formed artery or vein near the nerve is the culprit. The blood vessel can compress the nerve and cause problems. Rarely, TN may occur as a symptom of another underlying disorder, such as:

Risk Factors

These factors increase your chance of developing TN. Tell your doctor if you have any of these risk factors:

Symptoms

The main symptom is searing pain on one side of the face. The pain may be felt inside the mouth or in the lips, cheek, chin, nostril, ear, or near the eye. Rarely, pain may occur in the eye or forehead. Twitching or wincing sometimes accompanies the pain.
The pain is typically sudden, severe, and stabbing. Even though the pain is often brief (less than two minutes) it can reoccur hundreds of times per day. Attacks can become totally disabling. They may seem to occur at random or be triggered by extremes of temperature, washing, shaving, touching, or tickling the face. There are usually no symptoms between attacks, except perhaps a dull ache.

Diagnosis

The doctor will ask about your symptoms and medical history. A physical exam will be done.
Tests may be done to help diagnosis underlying conditions that may lead to TN. These may include:
  • CT scan —a type of x-ray that uses a computer to make pictures of structures inside the head
  • MRI scan —a test that uses magnetic waves to make pictures of structures inside the head
You may be given the antiseizure medication (eg, carbamazepine ). This medicine may reduce pain and is sometimes used to help diagnose the disorder.

Treatment

Treatment usually begins with medicine. If medicine fails, other options are available.

Medications

Medicines may include:
  • Carbamazepine
  • Other antiseizure medicines (eg, phenytoin , gabapentin , lamotrigine , oxcarbazepine , pregabalin , topiramate )
  • Low-dose antidepressants (eg, amitriptyline , clomipramine )
  • Muscle relaxer (eg, baclofen )
  • Other medicines, such as sumatriptan (Imitrex) injection, lidocaine nasal spray, pimozide (Orap)

Surgery

Surgical options include:
  • Surgery to remove an artery or tumor that is pressing on the nerve
  • Surgery to cut the trigeminal nerve
Surgery can be highly effective in some cases. The most common procedure is microvascular decompression.

Other Treatments

These procedures may be somewhat less effective than microvascular surgical decompression. But, they are widely used, especially in older patients.
  • Stereotactic radiosurgery
  • Injections of alcohol or glycerin to deaden the nerve
  • Injections of pain relievers or steroids to decrease inflammation/irritation of the nerve
  • High-frequency radio waves to deaden the nerve
  • Botulinum toxin injection (Botox)

Prevention

There are no guidelines for preventing TN. However, once you have it, steps that may help prevent attacks include:
  • Eating soft foods
  • Eating food and drinking beverages that are room temperature
  • Washing your face with cotton pads and warm water
  • If tooth brushing triggers attacks, rinsing your mouth with warm water after eating
  • Avoiding or minimizing known triggers (eg, heat, cold, touch)

RESOURCES

American Chronic Pain Association http://www.theacpa.org/

American Pain Foundation http://www.painfoundation.org/

The Facial Pain Association http://www.fpa-support.org/

CANADIAN RESOURCES

Canada TNA http://www.catna.ca/

Health Canada http://www.hc-sc.gc.ca/index%5Fe.html/

References

Chole R, Pati R, Degwekar SS, Bhowate RR. Drug treatment of trigeminal neuralgia: a systematic review of the literature. J Oral Maxillfac Surg . 2007; 65:40-45.

Current Medical Diagnosis and Treatment . 44th ed. Mcgraw-Hill; 2005.

Gorgulho A, DeSalles A. Trigeminal neuralgia: impact of radiosurgery on the surgical treatment of trigeminal neuralgia. Surgical Neurology . 2006;66:350-356.

Kalkanis SN, Eskandar EN, Carter BS, Barker FG II. Microvascular decompression surgery in the United States, 1996-2000: mortality rates, morbidity rates, and the effects of hospital and surgeon volumes. Neurosurgery . 2003;52:1251-1261.

NINDS trigeminal neuralgia information page. National Institute of Neurological Disorders and Stroke website. Available at: http://www.ninds.nih.gov/ . Updated February 2009. Accessed February 13, 2009.

Pollock BE, Ecker RD. A prospective cost-effectiveness study of trigeminal neuralgia surgery. Clin J Pain . 2005;21:317-22.

Trigeminal neuralgia. American Academy of Neurological Surgeons website. Available at: http://www.aans.org/Patient%20Information/Conditions%20and%20Treatments/Trigeminal%20Neuralgia.aspx . Accessed March 10, 2012.

Trigeminal neuralgia. EBSCO DynaMed website. Available at: http://www.ebscohost.com/dynamed/ . Updated February 3, 2012. Accessed March 10, 2012.

Viel M. Pregabalin for the treatment of trigeminal neuralgia. Am Fam Physician. 2008;78:808.

11/29/2006 DynaMed's Systematic Literature Surveillance DynaMed's Systematic Literature Surveillance : Kanai A, Saito M, Hoka S. Subcutaneous sumatriptan for refractory trigeminal neuralgia. Headache . 2006;46:577-82.

Revision Information

This content is reviewed regularly and is updated when new and relevant evidence is made available. This information is neither intended nor implied to be a substitute for professional medical advice. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with questions regarding a medical condition.

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