Trigeminal Neuralgia – Causes, Symptoms And Treatment

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    Trigeminal Neuralgia – Causes, Symptoms And Treatment

    Trigeminal neuralgia is the most common facial pain syndrome with paroxysmal character, representing one of the most unbearable pain. Also known as tic douloureux, trigeminal neuralgia has an incidence of 4.5 cases per 100,000 inhabitants and is characterized by recurrent episodes of pain, which starts in a small area of the face. Onset is most common in middle age, but have been reported cases with onset in childhood or in adolescence.

    Trigeminal nerve is the largest of all the cranial nerves, is a mixed nerve and presents two components: a sensory component which is formed by somatic sensory fibers that carry pain, temperature and touch sensations from the face and a motor component formed by motor fibers that supply temporalis, pterygoid, tensor tympani, tensor palati, mylohyoid, and anterior belly of the digastric muscle.

    Trigeminal Neuralgia Causes

    The exact pathophysiology of trigeminal neuralgia is not well known, in most cases the cause is not evident, being an idiopathic trigeminal neuralgia. In a small percentage of cases, trigeminal neuralgia may occur due to structural lesions of the trigeminal nerve.

    In most cases, trigeminal neuralgia is probably caused by the compression of an aberrant arterial or venous loop on the nerve root, produced where trigeminal root is entering into the pons. This mechanism first described by Jannetta in 1967 is still incriminated in 80% -90% of cases.

    Trigeminal Neuralgia

    Trigeminal Neuralgia

    Pulsations of arterial or venous vascular loops that produce aberrant trigeminal root compression, are responsible for the appearance of demyelination areas in the trigeminal root, which causes a non-synaptic transmission between sensory, thick , myelinated fibers and small, thin fibers that transmit pain. Aberrant arterial loops most often originate from superior cerebellar artery and anterior inferior cerebellar artery.

    In a lower proportion of cases, trigeminal neuralgia may be caused by a primary demyelination, as occurs in approximately 2% of cases of multiple sclerosis that is associated with trigeminal neuralgia.

    Trigeminal Neuralgia Symptoms

    The disease usually appears after age of 40 years, between 50 and 58 years, and most commonly affects females, the female/male ratio being 1,6:1 for women.

    Trigeminal neuralgia is characterized by a paroxysmal, repetitive, very strong and lancianting pain that is lasting a few seconds, described by the patient as a sensation of electrical shocks that starts suddenly. Attacks occur daily for several weeks or months, followed by a period of remission that may last for years and then attacks may recur. The pain is always located unilaterally, is so strong and sudden that the patient is frightened, may grimace, wince, or make an aversive head movement, reason why trigeminal neuralgia is also called tic douloureux.

    Paroxysmal pain attack lasts a few seconds, up to 20-30 seconds, rarely up to several minutes and during the day or night painful attacks can occur several times. The attack appear and disappear suddenly. Pain may occur spontaneously or is triggered by stimulation of specific areas located on the face, called trigger zones. Trigger zones are stimulated by low intensity stimuli, especially tactile or activities like teeth washing, yawning, talking, shaving and laughing. Pain may be precipitated by loud noises or bright stimuli. Most often the trigger zone is located on the nose or lips. After the active period of the disease, remissions can last for months or years, and recurrence of painful paroxysms  is unpredictable.

    Trigeminal Neuralgia

    Trigeminal Neuralgia

    Neuralgia occurs mostly on maxillary and mandibular branch, but were reported exceptional cases were neuralgia was located in the ophthalmic branch of the trigeminal nerve.

    Neurological examination reveals no changes in trigeminal nerve territory, which is an argument for the diagnosis of idiopathic trigeminal neuralgia. In evolution, trigeminal neuralgia tends to deterioration, painful attacks have the tendency to increase in frequency and severity.

    Trigeminal Neuralgia Treatment

    Trigeminal neuralgia benefit from medical treatment and neurosurgical treatment. Because trigeminal neuralgia affects patients older than 50 years, medical treatment should represent the initial therapy. Medical therapy is often sufficient and effective, allowing surgical consideration only if pharmacologic treatment fails.

    Medical Therapy

    Carbamazepine is the drug of choice in the treatment of trigeminal neuralgia. Dose should be increased gradually to obtain a maximum effect of the drug. After several weeks of symptoms improvement, the dose of carbamazepine may be decreased gradually. The most common side effects of carbamazepine are represented by skin rash, liver problems, ataxia and dizziness. Oxycarbamazepine has fewer side effects compared with carabamazepina and represent an other choice in trigeminal neuralgia.

    Phenytoin, clonazepam, baclofen, gabapentin and lamotrigine may be used either alone or in combination with carbamazepine.

    Baclofen is the second choice in the treatment of trigeminal neuralgia, especially in relapse cases. Dose should be increased gradually to obtain a maximum effect and can be administered alone or in combination with phenytoin or carbamazepine.

    Neurosurgical Procedures

    Trigeminal Neuralgia

    Trigeminal Neuralgia

    Neurosurgical procedure are applied to cases that are unresponsive to drug therapy and consist of:

    • Microvascular decompression;
    • Percutaneous radiofrequency rhizotomy;
    • Percutaneous radiofrequency trigeminal gangliolysis;
    • Percutaneous microcompression with balloon inflation;
    • Gamma knife surgery.

    3 COMMENTS

    1. Respected sir

      Iam living in india at cuddalore in tamilnadu state.

      Now iam suffering from facial pain .(facial nerve pain) daignosed trigeminal neuralgia,since 10 years.
      given carbamazipine,and prigabaline.Now stoped all drugs. because iam going to acupuncture treatment.but till now iam suffering from trigeminal nerve pain(madible and maxilary nerve).opthalmic nerve giving pain in the time of taking cabapentini.cabapentine is giving side effect to trigeminal opthalmic nerve.
      kaindly i request to you sir,give proper direction to me for treatment.
      thanking you
      yours faithfully
      s.sathiyarajmohan

    2. All antiseizure drugs caused impairing fogginess. Eventually I found that topical LIDOCAINE 2% VISCOUS placed inside the upper lip at the very top would stop the pain. This is where your dentist injects novicaine (like lidocaine), the very end of one branch of the trigeminal nerve. Recently, I saw a neurologist who very wisely prescribed the ORAL form of lidocaine, “mexiletine” (Mexitil)capsules, 150 mg to start.
      This durg stopped excruciating, overwhelming, exhausting pain within about 15 minutes! Incredible.
      Sometimes I need a higher dose (max is 900 mg to avoid side effects; otherwise there are NO side effects). This drug is used for heart spasms of the lower part of the heart at a higher dose. But at this dose, below 900 mg, there is no heart effect.
      It is very safe, without side effects, and extremely effective for “central” (originating in the brain as trigeminal neuralgia does) pain!
      Ask your doctor for mexiletine/Mexitil. It is a long-proven drug, available all over the world.
      If it ever stops working,I will have the “gamma knife” treatment.It does not involve opening up the skull,done at major medical centers by a neurosurgeon with very advanced and precise equipment (UCSF, Stanford, Univ of Washington). It takes a short time, and there is total remission within three weeks.
      An old friend has had the gamma knife treatment four times now, each time lasting for 5-7 years, and has been able to give college lectures and travel widely to conferences to give presentations. She also publishes books on her work in literature (John Milton) and lectures on the psychoanalysis of pain in major medical schools–so she is urging me to get the gamma knife treatment ASAP. Meanwhile, Mexitil and using the lidocaine on gauze strips under my upper lip stop the pain! Completely.
      Be sure to use the treatment as soon as possible after an attack begins to interrupt the pain to keep the pain gates from opening more. No reason to go through this.
      My pain goes from the roof of my mouth, up through my sinus bone, through the eyelid and eyebrow, the forehead, and into the edge of the scalp. These sites spread after I had “shingles” on the same side about eight years ago; the pain had followed a dental infection (dry sccket)in a tooth next to the “eye tooth” in 2000.
      I feel very, very lucky to have found both lidocaine (on the skin or in the mouth) and then Mexitil. Pain only recurs rarely now that the nerve is not being stimulated, I assume.

    3. By the way, my pain was deemed “intractable”, since no drugs would interrupt it, and I was referred to a neurosurgeon for the gamma knife treatment. It is the most severe kind of trigeminal neuralgia. because it’s complicated by “post-herpetic neuralgia” (PHN)
      Please ask your doctor for mexiletine (Mexitil is easier to spell);in the meantime, use the topical (surface) lidocaine– only the 2% viscous lidocaine will work. I was happy to find this specific form verified as uniquely effective in clinical research articles.
      There is a lidocaine patch that’s used for severe pain, too, but I’d rather use this goo in my mouth than have a patch on my face. Some people put the lidocaine gel on their skin; I’ve used this for the sinus bone and eye pain in the past not as effective as putting it under your upper lip, good as a supplement. But try the oral capsule, the Mexitil, as well– much more effective. lasts for 4-8 hours.

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