Trigeminal Neuralgia – Causes, Symptoms, Diagnosis, Treatment

Trigeminal neuralgia (TN or TGN) is a chronic pain uncommon disorder characterized by recurrent attacks of lancinating pain in the trigeminal nerve distribution that affects the trigeminal nerve. Typically, brief attacks are triggered by talking, chewing, teeth brushing, shaving, a light touch, or even a cool breeze. The pain is nearly always unilateral, and it may occur repeatedly throughout the day.[Rx]

Trigeminal neuralgia (TN), also called tic douloureux, is a chronic pain condition that affects the trigeminal or 5th cranial nerve, one of the most widely distributed nerves in the head. TN is a form of neuropathic pain (pain associated with nerve injury or nerve lesion.) The typical or “classic” form of the disorder (called “Type 1” or TN1) causes extreme, sporadic, sudden burning or shock-like facial pain that lasts anywhere from a few seconds to as long as two minutes per episode.  These attacks can occur in quick succession, in volleys lasting as long as two hours.  The “atypical” form of the disorder (called “Type 2” or TN2), is characterized by constant aching, burning, stabbing pain of somewhat lower intensity than Type 1.  Both forms of pain may occur in the same person, sometimes at the same time. The intensity of pain can be physically and mentally incapacitating.

Types of Trigeminal Neuralgia

There are two main types: typical and atypical trigeminal neuralgia.

  • The typical trigeminal neuralgia – form results in episodes of severe, sudden, shock-like pain in one side of the face that lasts for seconds to a few minutes. Groups of these episodes can occur over a few hours.
  • The atypical trigeminal neuralgia – form results in a constant burning pain that is less severe. Episodes may be triggered by any touch to the face. Both forms may occur in the same person. It is one of the most painful conditions and can result in depression.

 

Anatomy Trigeminal Neuralgia

The brain is connected to the body by the spinal cord with spinal nerves sending and receiving impulses and messages to and from the brain. However, there are twelve cranial nerves that directly connect to the body. These nerves are involved with the muscle and sensory function of the head and neck. (The exception is cranial nerve X or the vagus nerve, which is also responsible for the parasympathetic system of the chest and abdomen).

The nerve has three branches that conduct sensations from the upper, middle, and lower portions of the face, as well as the oral cavity, to the brain. The ophthalmic, or upper, branch supplies sensation to most of the scalp, forehead, and front of the head. The maxillary, or middle, branch stimulates the cheek, upper jaw, top lip, teeth and gums, and to the side of the nose. The mandibular, or lower, branch supplies nerves to the lower jaw, teeth and gums, and bottom lip.

Function I

12 Cranial Nerves
Cranial Nerve
Name
functions
Smell
II
Optic
Vision
III, IV, VI
Oculomotor, Trochlear, Abducens
Eye movement
V
Trigeminal
Facial sensation, chewing
VII
Facial
Facial movement
VIII
Auditory
Hearing
IX
Glossopharyngeal
Taste, swallowing
X
Vagus
Swallowing, voice modulation, the parasympathetic tone of the body
XI
Accessory
Neck muscles
XII
Hypoglossal
Swallowing, speech articulation

The trigeminal nerve (cranial nerve V) is so named because it has three (tri) branches responsible for face sensation; one branch also regulates chewing.

  • The ophthalmic branch (V1) – is responsible for sensation from the scalp, forehead, upper eyelid and tip of the nose.
  • The maxillary branch (V2) – sensation covers the lower eyelid, the side of the nose, the upper lip and cheek, and the upper teeth and gums.
  • The mandibular branch (V3) – is responsible for sensation than of the lower teeth and gums, lower lip, chin, jaw, and part of the ear. It is also responsible for supplying the muscles involved with chewing (mastication), those muscles involved with chewing.

rxharun.com/trigeminal-nerve-12-638-(1)

Causes of Trigeminal Neuralgia

TN is associated with a variety of conditions. TN can be caused by a blood vessel pressing on the trigeminal nerve as it exits the brain stem. This compression causes the wearing away or damage to the protective coating around the nerve (the myelin sheath). TN symptoms can also occur in people with multiple sclerosis, a disease that causes deterioration of the trigeminal nerve’s myelin sheath. Rarely, symptoms of TN may be caused by nerve compression from a tumor, or a tangle of arteries and veins called an arteriovenous malformation. Injury to the trigeminal nerve (perhaps the result of sinus surgery, oral surgery, stroke, or facial trauma) may also produce neuropathic facial pain.

  • In trigeminal neuralgia, also called tic douloureux, the trigeminal nerve’s function is disrupted. Usually, the problem is contact between a normal blood vessel in this case, an artery or a vein — and the trigeminal nerve at the base of your brain. This contact puts pressure on the nerve and causes it to malfunction.
  • Trigeminal neuralgia can occur as a result of aging, or it can be related to multiple sclerosis or a similar disorder that damages the myelin sheath protecting certain nerves. Less commonly, trigeminal neuralgia can be caused by a tumor compressing the trigeminal nerve.
  • Most cases of trigeminal neuralgia are believed to be caused by blood vessels pressing on the root of the trigeminal nerve. This is said to make the nerve transmit pain signals which are experienced as the stabbing pains of trigeminal neuralgia. However, experts are not completely sure of the cause. Pressure on the trigeminal nerve may also be caused by a tumor or multiple sclerosis.

Below is a list of known and suspected causes

  • A blood vessel presses – against the root of the trigeminal nerve.
  • Multiple sclerosis – due to demyelination of the nerve. Trigeminal neuralgia typically appears in the advanced stages of multiple sclerosis.
  • A tumor presses –  against the trigeminal nerve. This is a rare cause.
  • Physical damage to the nerve – this may be the result of injury, a dental or surgical procedure, or infection.
  • Family history (genes, inherited) – 4.1% of patients with unilateral trigeminal neuralgia (affects just one side of the face) and 17% of those with bilateral trigeminal neuralgia (affects both sides of the face) have close relatives with the disorder. Compared to a 1 in 15,000 risks in the general population, 4.1% and 17% indicate that inheritance is probably a factor

A variety of triggers may set off the pain of trigeminal neuralgia, including

  • Shaving
  • Touching your face
  • Eating
  • Drinking
  • Brushing your teeth
  • Talking
  • Putting on makeup
  • Encountering a breeze
  • Smiling
  • Washing your face

Symptoms of Trigeminal Neuralgia

TN presents as attacks of stabbing unilateral facial pain, most often on the right side of the face. The number of attacks may vary from less than 1 per day to 12 or more per hour and up to hundreds per day.

Pain varies, depending on the type of TN, and may range from sudden, severe, and stabbing to a more constant, aching, burning sensation. The intense flashes of pain can be triggered by vibration or contact with the cheek (such as when shaving, washing the face, or applying makeup), brushing teeth, eating, drinking, talking, or being exposed to the wind. The pain may affect a small area of the face or may spread. Bouts of pain rarely occur at night, when the affected individual is sleeping.[rx]

Triggers of pain attacks include the following

  • Chewing, talking or smiling
  • Drinking cold or hot fluids
  • Touching, shaving, brushing teeth, blowing the nose
  • Encountering cold air from an open automobile window

Pain localization is as follows

  • Patients can localize their pain precisely
  • The pain commonly runs along the line dividing either the mandibular and maxillary nerves or the maxillary and ophthalmic portions of the nerve
  • In 60% of cases, the pain shoots from the corner of the mouth to the angle of the jaw
  • In 30%, pain jolts from the upper lip or canine teeth to the eye and eyebrow, sparing the orbit itself
  • In less than 5% of cases, pain involves the ophthalmic branch of the facial nerve

The pain has the following qualities

  • Characteristically severe, paroxysmal, and lancinating
  • Commences with a sensation of electrical shocks in the affected area
  • Crescendos in less than 20 seconds to an excruciating discomfort felt deep in the face, often contorting the patient’s expression
  • Begins to fade within seconds, only to give way to a burning ache lasting seconds to minutes
  • Pain fully abates between attacks, even when they are severe and frequent
  • Attacks may provoke patients to grimace, wince, or make an aversive head movement, as if trying to escape the pain, thus producing an obvious movement, or tic; hence the term “tic douloureux”

Other diagnostic clues are as follows

  • Patients carefully avoid rubbing the face or shaving a trigger area, in contrast to other facial pain syndromes, in which they massage the face or apply heat or ice
  • Many patients try to hold their face still while talking, to avoid precipitating an attack
  • In contrast to migrainous pain, attacks of TN rarely occur during sleep

Diagnosis of Trigeminal Neuralgia

  • No laboratory, electrophysiologic, or radiologic testing is routinely indicated for the diagnosis of TN, as patients with a characteristic history and normal neurologic examination may be treated without further workup.
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Strict criteria for TN as defined by the International Headache Society (IHS) are as follows :

  • A – Paroxysmal attacks of pain lasting from a fraction of a second to 2 minutes, affecting 1 or more divisions of the trigeminal nerve and fulfilling criteria B and C
  • B – Pain has at least 1 of the following characteristics: (1) intense, sharp, superficial or stabbing; or (2) precipitated from trigger areas or by trigger factors
  • C – Attacks stereotyped in the individual patient
  • D – No clinically evident neurologic deficit
  • E – Not attributed to another disorder

IHS criteria for symptomatic TN vary slightly from the strict criteria and include the following 

  • A – Paroxysmal attacks of pain lasting from a fraction of a second to 2 minutes, with or without persistence of aching between paroxysms, affecting 1 or more divisions of the trigeminal nerve and fulfilling criteria B and C
  • B – Pain has at least 1 of the following characteristics: (1) intense, sharp, superficial or stabbing; or (2) precipitated from trigger areas or by trigger factors
  • C – Attacks stereotyped in the individual patient
  • D – A causative lesion, other than vascular compression, demonstrated by special investigations and/or posterior fossa exploration

A blood count and liver function tests are required if therapy with carbamazepine is contemplated. Oxcarbazepine can cause hyponatremia, so the serum sodium level should be measured after the institution of therapy.

Treatment of Trigeminal Neuralgia

Anticonvulsant medicines—used to block nerve firing—are generally effective in treating TN1 but often less effective in TN2. These drugs include carbamazepine, oxcarbazepine, topiramate, gabapentin, pregabalin, clonazepam, phenytoin, lamotrigine, and valproic acid.

Tricyclic antidepressants such as amitriptyline or nortriptyline can be used to treat pain. Common analgesics and opioids are not usually helpful in treating the sharp, recurring pain caused by TN1, although some individuals with TN2 do respond to opioids.

There are several effective ways to alleviate the pain, including a variety of medications.

  • Carbamazepine, an anticonvulsant drug, is the most common medication that doctors use to treat trigeminal neuralgia. In the early stages of the disease, carbamazepine controls pain for most people. When a patient shows no relief from this medication, a physician has cause to doubt whether trigeminal neuralgia is present. However, the effectiveness of carbamazepine decreases over time. Possible side effects include dizziness, double vision, drowsiness, and nausea.
  • Baclofen is a muscle relaxant. Its effectiveness may increase when it is used with either carbamazepine or phenytoin. Possible side effects include confusion, depression, and drowsiness.
  • Phenytoin, an anticonvulsant medication, was the first medication used to treat trigeminal neuralgia. Possible side effects include gum overgrowth, balance disturbances, and drowsiness.
  • Oxcarbazepine, a newer medication, has been used more recently as the first line of treatment. It is structurally related to carbamazepine and may be preferred because it generally has fewer side effects. Possible side effects include dizziness and double vision.
  • Other medications include gabapentin, clonazepam, sodium valporate, lamotrigine and topiramate.
  • Lamotrigine 200–400 mg –  as add-on therapy was shown to be an effective and safe treatment, in comparison with CBZ alone, for management of TN [] in 67 % of included patients with a mean age of 63 years (range 44–84). The reported side effects were a headache, dizziness, and a skin rash.
  • Tizanidine 12–18 mg  – showed no greater effectiveness than CBZ or placebo in 22 patients, with response rates of 56 % for tizanidine, 66 % for CBZ, and 40 % for placebo [].
  • Baclofen –  was superior to placebo in reducing the number of painful paroxysms, with a 70 % response rate in 10 patients with a mean age of 64 years (range 36–77) []. In a small group of 12 patients, tocainide was as effective as CBZ in reducing the frequency and severity of pain attacks on a Visual Analogue Scale (VAS), with a response rate of 75 % [].
  • Pimozide – was even more effective than CBZ in a single trial including 48 patients, with a response rate of 100 % for pimozide versus 56 % for CBZ []. The reported side effects were physical and mental retardation, hand tremors, and memory impairment in 83 % of the pimozide group. Drugs with local administration have been studied in single trials as well.
  • Topical ophthalmic anesthesia (proparacaine) –  was not effective in a single placebo-controlled trial in 47 patients [].
  • Botulinum toxin (BTX) type A – administered subcutaneously, proved to be effective (with a 50 % response rate, defined as a decrease in the VAS score of >50 %) in three placebo-controlled trials, which included a total of 102 patients with a mean age of 57 years (range 30–88) []. The reported side effects were transient, such as facial asymmetry, hematoma, or edema.
  • Sumatriptan – administered subcutaneously, was more effective than placebo (response rate 83 %) in a single trial in a small group of 24 patients []. Lidocaine 8 % applied on the mucosa or administered via the intranasal route was effective in 85 % of 49 patients in two placebo-controlled trials, but the effect diminished after approximately 3 h [].

Follow chart

Type Drug Brand Name Manufacturer
Anti-epileptic Carbamazepine Carbatrol, Equetro, Tegretol, Tegretol XR Shire Pharmaceuticals, Validus Pharmaceuticals, Novartis Pharmaceuticals
Anti-epileptic Felbamate Felbatol Meda Pharmaceuticals
Anti-epileptic Gabapentin Neurontin Pfizer
Anti-epileptic Lamotrigine Lamictal GlaxoSmithKline
Anti-epileptic Levetiracetam Keppra UCB
Anti-epileptic Oxcarbazepine Trileptal Novartis Pharmaceuticals
Anti-epileptic Pregabalin Lyrica Pfizer
Anti-epileptic Tiagabine Gabitril Cephalon
Anti-epileptic Topiramate Topamax Ortho-McNeil-Janssen Pharmaceuticals
Anti-epileptic Valproate Depakote, Depakote ER, Depakene, Depacon, Valproate, Valrelease Abbott Laboratories
Anti-epileptic Zonisamide Zonegran Dainippon
Anti-spasticity Baclofen Lioresal, Lioresal Intrathecal, Gablofen Various Drug Companies
Anti-epileptic Phenytoin Dilantin, Phenytek
Anti-epileptic Clonazepam Klonopin, Rivatril
Anti-depressant Amitriptyline Elavil
Anti-depressant Protriptyline Vivactil
Anti-depressant Nortriptyline Pamelor
Anti-depressant Fluoxetine Prozac, Seronil, Fontex
Anti-depressant Trazodone Desyrel
Opioids Morphine
Opioids Codeine
Opioids Fentanyl
Opioids Hydrocodone
Opioids Hydromorphone
Dermatologic Lidocaine
Dermatologic Lidoderm patch
Dermatologic Lidocaine cream
Dermatologic Capsaicin
Antianxiety SSRIs Paxil, Celexa
Antianxiety Benzodiazepines Ativan, Valium, Xanax, Klonopin
Analgesic Ultram Tramadol
Analgesic Ketamine
SNRIS Venlafaxine Effexor – serotonin/norepinephrine reuptake inhibitors
SNRIS Duloxetine Cymbalta – serotonin and noradrenaline reuptake inhibitor

Surgery of Trigeminal Neuralgia

If medications have proven ineffective in treating trigeminal neuralgia, there are several surgical procedures that may help control the pain. Surgical treatment is divided into two categories: percutaneous (through the skin) and open. In general, percutaneous approaches are preferred in older or medically frail patients, in patients with multiple sclerosis, or in individuals who have failed to attain pain relief from the open approach. The open approach is recommended for younger and healthier patients. All of the procedures have varying success rates and some side effects, such as recurrence of pain and facial numbness.

  • Microvascular decompression – involves microsurgical exposure of the trigeminal nerve root, identification of a blood vessel that may be compressing the nerve, and gentle movement of the blood vessel away from the point of compression. Decompression may reduce sensitivity and allow the trigeminal nerve to recover and return to a more normal, pain-free condition. While this generally is the most effective surgery, it also is the most invasive, because it requires opening the skull through a craniotomy. There is a small risk of decreased hearing, facial weakness, facial numbness, double vision, and stroke or death. The risk of facial numbness, however, is less likely with procedures that involve damaging the trigeminal nerve.
  • Percutaneous stereotactic rhizotomy – Treats trigeminal neuralgia through the use of electrocoagulation (heat). It can relieve nerve pain by destroying the part of the nerve that causes pain and suppressing the pain signal to the brain. The surgeon passes a hollow needle through the cheek into the trigeminal nerve. A heating current, which is passed through an electrode, destroys some of the nerve fibers.
  • Percutaneous glycerol rhizotomy – Utilizes glycerol injected through a needle into the area where the nerve divides into three main branches. The goal is to damage the nerve selectively in order to interfere with the transmission of the pain signals to the brain.
  • Percutaneous balloon compression – Utilizes a needle that is passed through the cheek to the trigeminal nerve. The neurosurgeon places a balloon in the trigeminal nerve through a catheter. The balloon is inflated where fibers produce pain. The balloon compresses the nerve, injuring the pain-causing fibers. After several minutes, the balloon and catheter are removed.
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  • Stereotactic radiosurgery – (through such procedures as Gamma Knife, Cyberknife, LINAC) delivers a single highly concentrated dose of ionizing radiation to a small, precise target at the trigeminal nerve root. This treatment is non-invasive and avoids many of the risks and complications of open surgery and other treatments. Over a period of time and as a result of radiation exposure, the slow formation of a lesion in the nerve interrupts the transmission of pain signals to the brain.
  • Motor cortex stimulation – is another option, but often is considered a last resort because it can be very difficult to predict which patients may benefit. While about half of patients experience pain relief, it tends to be short-term. This is an open procedure with all of the risks of microvascular decompression, but without the high success rates. The benefits of surgery should always be weighed carefully against its risks. Although a large percentage of trigeminal neuralgia patients report pain relief after surgery, there is no guarantee that surgery will help every individual.
  • Percutaneous procedures on the Gasserian ganglion-gamma knife and microvascular decompression are recommended, efficacy-proven surgical treatment options for medical refractory TN. Surgery for TN is either destructive (ablative), where the trigeminal nerve sensory function is intentionally destroyed, or non-destructive, where the trigeminal nerve is decompressed preserving its normal function.
  • Gasserian ganglion percutaneous techniques –  are all destructive and include radiofrequency thermocoagulation (RFT), balloon compression (BC) and percutaneous glycerol rhizolysis (PGR). Ninety percent of patients report pain relief following these procedures. After 1 year, 68–85% of patients are still pain-free, after 3 years this is reduced to 54–64% and after 5 years only 50% of patients are still pain-free following RFT. The most common side effects are sensory loss (50%) which extremely decreases the quality of life [], dysesthesias (6%), anesthesia Dolorosa (4%), corneal numbness with the risk of keratitis (4%). Gasserian ganglion therapies require short-acting anesthetics, are primarily overnight minor procedures with extremely low mortality [].
  • In gamma knife surgery – a focused beam of radiation is aimed at the trigeminal root in the posterior fossa. One year after gamma knife surgery, 69% of patients are pain-free without additional medication. At 3 years, 52% are still pain-free. The development of pain relief can be delayed (mean 1 month). Side effects are sensory complications in 6% that may develop with a delay of up to 6 months, facial numbness in 9–37% which improves over time and paresthesias in 6–13% []. Quality of life improves by 88% []. The main disadvantage of gamma knife surgery is the treatment expense that limits widespread usage making it a reserve treatment option for patients that cannot undergo open surgery or have blood coagulation problems (e.g. are receiving warfarin).
  • Microvascular decompression – achieves the most sustained pain relief with 90% of patients reporting initial pain relief and over 80% still pain-free after 1 year, with 75% after 3 years and 73% after 5 years remaining pain-free. It is, however, a major surgical procedure that entails craniotomy to reach the trigeminal nerve in the posterior fossa. The average mortality rate ranges from 0.2% to 0.5%, and up to 4% of patients suffer from major problems such as cerebrospinal fluid (CSF) leakage, infarcts or hematomas. The most common complications are aseptic meningitis (11%), sensory loss (7%) and hearing loss (10%) as long-term complications [].

Surgery In Advance stage

A rhizotomy (rhizolysis) is a procedure in which nerve fibers are damaged to block pain. A rhizotomy for TN always causes some degree of sensory loss and facial numbness. Several forms of rhizotomy are available to treat trigeminal neuralgia:

  • Balloon compression – works by injuring the insulation on nerves that are involved with the sensation of light touch on the face. The procedure is performed in an operating room under general anesthesia. A tube called a cannula is inserted through the cheek and guided to where one branch of the trigeminal nerve passes through the base of the skull. A soft catheter with a balloon tip is threaded through the cannula and the balloon is inflated to squeeze part of the nerve against the hard edge of the brain covering (the dura) and the skull. After about a minute the balloon is deflated and removed, along with the catheter and cannula. Balloon compression is generally an outpatient procedure, although sometimes the patient may be kept in the hospital overnight. Pain relief usually lasts one to two years.
  • Glycerol injection – is also generally an outpatient procedure in which the individual is sedated with intravenous medication. A thin needle is passed through the cheek, next to the mouth, and guided through the opening in the base of the skull where the third division of the trigeminal nerve (mandibular) exits. The needle is moved into the pocket of spinal fluid (cistern) that surrounds the trigeminal nerve center (or ganglion, the central part of the nerve from which the nerve impulses are transmitted to the brain). The procedure is performed with the person sitting up, since glycerol is heavier than spinal fluid and will then remain in the spinal fluid around the ganglion. The glycerol injection bathes the ganglion and damages the insulation of trigeminal nerve fibers. This form of rhizotomy is likely to result in recurrence of pain within a year to two years. However, the procedure can be repeated multiple times.
  • Radiofrequency thermal lesioning – (also known as “RF Ablation” or “RF Lesion”) is most often performed on an outpatient basis. The individual is anesthetized and a hollow needle is passed through the cheek through the same opening at the base of the skull where the balloon compression and glycerol injections are performed. The individual is briefly awakened and a small electrical current is passed through the needle, causing tingling in the area of the nerve where the needle tips rests. When the needle is positioned so that the tingling occurs in the area of TN pain, the person is then sedated and the nerve area is gradually heated with an electrode, injuring the nerve fibers.  The electrode and needle are then removed and the person is awakened. The procedure can be repeated until the desired amount of sensory loss is obtained; usually a blunting of sharp sensation, with preservation of touch. Approximately half of the people have symptoms that reoccur three to four years following RF lesioning. Production of more numbness can extend the pain relief even longer, but the risks of anesthesia dolorosa also increase.
  • Stereotactic radiosurgery – (Gamma Knife, Cyber Knife) uses computer imaging to direct highly focused beams of radiation at the site where the trigeminal nerve exits the brain stem. This causes the slow formation of a lesion on the nerve that disrupts the transmission of sensory signals to the brain. People usually leave the hospital the same day or the next day following treatment but won’t typically experience relief from pain for several weeks (or sometimes several months) following the procedure.  The International RadioSurgery Association reports that between 50 and 78 percent of people with TN who are treated with Gamma Knife radiosurgery experience “excellent” pain relief within a few weeks following the procedure. For individuals who were treated successfully, almost half have recurrence of pain within three years.
  • Microvascular decompression (MVD) – is the most invasive of all surgeries for TN, but also offers the lowest probability that pain will return. About half of individuals undergoing MVD for TN will experience recurrent pain within 12 to 15 years.  This inpatient procedure, which is performed under general anesthesia, requires that a small opening be made through the mastoid bone behind the ear. While viewing the trigeminal nerve through a microscope or endoscope, the surgeon moves away the vessel (usually an artery) that is compressing the nerve and places a soft cushion between the nerve and the vessel. Unlike rhizotomies, the goal is not to produce numbness in the face after this surgery. Individuals generally recuperate for several days in the hospital following the procedure, and will generally need to recover for several weeks after the procedure.
  • A neurectomy (also called partial nerve section) – which involves cutting part of the nerve, may be performed near the entrance point of the nerve at the brain stem during an attempted microvascular decompression if no vessel is found to be pressing on the trigeminal nerve. Neurectomies also may be performed by cutting superficial branches of the trigeminal nerve in the face. When done during microvascular decompression, a neurectomy will cause more long-lasting numbness in the area of the face that is supplied by the nerve or nerve branch that is cut. However, when the operation is performed in the face, the nerve may grow back and in time sensation may return.  With neurectomy, there is risk of creating anesthesia dolorosa.
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Surgical treatment for TN2 is usually more problematic than for TN1, particularly where vascular compression is not detected in brain imaging prior to a proposed procedure. Many neurosurgeons advise against the use of MVD or rhizotomy in individuals for whom TN2 symptoms predominate over TN1, unless vascular compression has been confirmed. MVD for TN2 is also less successful than for TN1.

Alternative Treatment of Trigeminal Neuralgia

  • Ignition hypothesis – According to the ignition hypothesis, based on recent advances in the understanding of the electrical behavior of injured sensory neurons and on findings from histopathologic observations obtained from patients undergoing MVD, injury of trigeminal afferent neurons in the trigeminal root or ganglion makes these axons and axotomized somata hyperexcitable, giving rise to pain paroxysms as a result of synchronized afterdischarge activity.
  • Transcranial magnetic stimulation – Repetitive transcranial magnetic stimulation (rTMS) is an emerging technology that introduces the possibility of assessing whether patients with trigeminal neuropathic pain will respond to direct epidural cortical stimulation by first measuring their response to a trial of non-invasive cortical stimulation. In a study of 24 TN patients given rTMS to the motor cortex at 20 Hz daily for 5 days, pain ratings decreased by approximately 45% for 2 weeks []. In a different study of 12 patients with chronic intractable TN who had failed surgical treatment, 58% experienced a greater than 30% reduction in pain after receiving repetitive TMS [].
  • Alternative Medicine – This section contains a wide variety of so-called “alternative” treatments. Some are medical treatments that are generally used for other purposes, but which have anecdotally been used to try to treat facial neuralgia pain. Most of this anecdotal information has been gathered from feedback with facial neuralgia sufferers. They may or may not be effective; the important point is that someone has tried them. Some of the treatments in this category are what is often known as “pseudo-scientific”. That is, there seems to be no rigorous scientific basis for them.
  • Anesthetics – There is some anecdotal evidence for the use of various anesthetic substances for treating acute attacks of facial neuralgias. Some of these substances should only be used under professional supervision. In general, any pain relief is likely to be short-lived. In addition, these treatments are probably more effective for cases of atypical TN than for classical TN.
  • Capsaicin – Has been anecdotally used, especially for atypical forms of TN and atypical facial pain. This is becoming more of a mainstream treatment and possibly should be included as a standard drug treatment instead of an alternative treatment.
  • Lidocaine cream/patch –  Again, relatively harmless if used properly.
  • Lidocaine nose sprays
  • Therapeutics – This group includes a variety of substances that have been suggested for facial neuralgia pain. Some of the substances may raise controversy, but an attempt has been made to avoid listing any substances that are directly harmful or poisonous.
  • Herbal remedies – various herbal regimes have been suggested for TN.
  • Homeopathy – a controversial treatment, but has been used by some.
  • Vitamin B12 –In her B12 study “DO TN patients have a B12 deficiency and Is there a role of Vitamin B12 in TN Management:  Irene Wood found those who used B12 supplements were able to lessen their pain, and some were also able to achieve “no pain no medication. Many in our Association are now using B12 supplements to help manage their pain. The hypothesis is repairing of the myelin (re-myelination). Low Vitamin B12 Syndrome in Trigeminal Neuralgia.
  • Musculoskeletal – These treatments treat the muscles rather than dealing with the nerve directly. At the very least, this relaxation can make it easier to deal with the pain. It is also possible that some cases of facial neuralgias are made worse by muscular strain, in which case these treatments could provide direct help. For classical TN, these treatments are likely to have little effect; however, they may well help those with more atypical symptoms.
  • ChiropracticAtlas Orthogonal Chiropractic focuses on aligning the C1, C2. Has helped others in achieving pain-free.
  • Myotherapy/myofascial release therapy
  • Cranial Osteopathy/Craniosacral therapy
  • Acupuncture – These treatments treat the nervous system directly (at least in theory). For lack of a better term, they can be classified under the term acupuncture-like. All have been reported to be used for facial neuralgia pain; as with all alternative treatments, the results have been inconclusive. It is used relatively common; however, reliable success rates are almost impossible to calculate.
  • Laser treatment – new, experimental treatment. The mechanism may be somewhat similar to acupuncture
  • Moxa therapy – similar to normal acupuncture.
  • TENS – electrical treatment; effects may be similar to acupuncture.
  • Psychological Hypnosis – This has been suggested for atypical as well as classical forms of TN. Only anecdotal evidence for it seems to exist so far. However, even some reputable textbooks do mention it as a reputable treatment.

Who is affected?

Trigeminal neuralgia occurs most often in people over age 50, although it can occur at any age, including infancy. The possibility of TN being caused by multiple sclerosis increases when it occurs in young adults. The incidence of new cases is approximately 12 per 100,000 people per year; the disorder is more common in women than in men.


References

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