What is Trigeminal Neuralgia?
Trigeminal Neuralgia is defined as pain coming from the trigeminal nerve. The trigeminal nerve starts at the top of the ear and splits into three parts, one towards the eye (ophthalmic nerve), one towards the cheek (maxillary nerve), and finally one towards the jaw (mandivular nerve).
Causes of Trigeminal Neuralgia
Trigeminal Neuralgia is can be caused by various factors, including:
Cranio-orofacial trauma: Certain dental, surgical, or anesthetic procedures or physical facial trauma, such as motor vehicle accidents or other injuries, could lead to Trigeminal Neuralgia.
Multiple Sclerosis: This is a disease where the protective covering of myelin sheaths around the nerves is damaged. Other diseases with similar symptoms could also cause Trigeminal Neuralgia.
Arteriovenous malformation: Blood vessels irregularly connect to arteries and veins, causing a disturbance of blood and oxygen flow in the body. This could lead to enlarged blood vessels which lead to the trigeminal nerve root becoming compressed.
Aging: As people get older, their myelin sheaths which protect nerve fibers, can deteriorate which leads to improper nerve signaling. Trigeminal Neuralgia is more common among adults ages 50 and older.
Hypertension: This condition, also known as high blood pressure, occurs when the force of blood pushing against artery walls is too high. This could lead to Trigeminal Neuralgia as blood vessels expand and compress the trigeminal nerve.
The cause of trigeminal neuralgia is the disruption of the function of the trigeminal nerve. This can occur through:
Contact between a blood vessel and the trigeminal nerve: Contact between a blood vessel (vein or artery) with the trigeminal nerve results in pressure being placed on the nerve, which ultimately impairs the function.
Multiple sclerosis: Any conditions that damage the myelin sheath of nerve cells, such as multiple sclerosis, can cause trigeminal neuralgia as the myelin sheath serves as protection for the nerve cells. The loss of the myelin sheath can lead the nerve to be very sensitive.
Brain tumor: A tumor coming into contact with the trigeminal nerve can result in impaired function of the nerve.
Facial trauma or dental procedures: Trauma can induce damage to the trigeminal nerve, which can result in neuralgia.
Symptoms of Trigeminal Neuralgia
Pain from Trigeminal Neuralgia typically occurs on one side of the face (occasionally both sides) and is often triggered from the slightest stimuli (brushing teeth, shaving, applying makeup, talking, drinking, eating, or even a light breeze hitting the face). At first, you may experience short, mild episodes of pain, but as the condition progresses, pain may get worse, happen more often, and last longer. This pain can often be described as:
Sharp, stabbing or shooting
Electric shock-like sensations
Burning or crushing pain
Numbness or dull achiness
There are a variety of pain-related symptoms associated with Trigeminal neuralgia, but these are commonly reported symptoms:
Episodes of intense shooting pain that feels like an electrical shock that last for a few seconds to several minutes.
Sudden episodes of pain caused by chewing, brushing, speaking or touching one’s face.
Pain in the cheeks, jaw, teeth, gum or lips, and occasionally the eye and forehead.
Episodes of pain that become more frequent and intense over time.
Prognosis of Trigeminal Neuralgia
The prognosis of Trigeminal Neuralgia is not life-threatening, but it often leads to chronic pain and disability. Over time, Trigeminal Neuralgia stops responding to medication/treatment and more intervention is required to manage the pain. There are two main forms of Trigeminal Neuralgia:
Paroxysmal Trigeminal Neuralgia: This form is denoted by sharp and intense pain, but it is less frequent. Episodes can feel like burning and last from a few seconds to two minutes. However, there can be pain-free breaks.
Trigeminal Neuralgia with continuous pain: This form is often less painful and less intense, but there are more frequent episodes of pain which are constant and considered stabbing/burning. There may be more difficulty managing symptoms for this form.
Impact of Trigeminal Neuralgia
Trigeminal Neuralgia often leads to anxiety, depression, social isolation, weight loss, and other mental health issues if adequate treatment and therapy is not administered. This condition could also lead to facial muscle spasms, facial numbness, or jaw weakness.
Diagnosis of Trigeminal Neuralgia
Diagnosis of trigeminal neuralgia is typically done by a healthcare provider based on the description of the pain you are experiencing. Descriptions such as an electric shock feeling or specific triggers for pain can be indicative of trigeminal neuralgia.
Diagnosing cervical stenosis typically involves:
Physical Examination: Assessment of reflexes, muscle strength, and sensation.
Neurological Examination: Assessment of brain and nervous system functioning. This examination may involve testing mental status and movements.
Diagnostic Imaging: Brain MRIs are typically used to identify the cause of Trigeminal Neuralgia, such as pressure from a blood vessel or tumor.
Causes of trigeminal neuralgia can be identified through:
A neurological exam: Different parts of a neurological exam, such as physical examination and reflex tests can help identify the branches of the trigeminal nerve that are affected and if a compressed nerve is causing this pain.
Magnetic Resonance Imaging (MRI): An MRI can help identify multiple sclerosis or a tumor pressing against the trigeminal nerve. Additionally, a dye can be used within an MRI to view the blood vessels and see if any of these blood vessels are in contact with the trigeminal nerve.
Treatment of Trigeminal Neuralgia
Treatment options include:
Conventional Treatments: This is often the initial therapeutic intervention that will be considered to manage symptoms.
Antiepileptic Medications: These medications have agents which bind to voltage-gated sodium channels and control pain. They are initially administered at a low dose and slowly increased over time to manage pain more efficiently.
Baclofen: Exercises to strengthen neck muscles and improve range of motion.
Epidural Steroid Injections: Targeted injections to reduce inflammation and alleviate pain.
Acupuncture: Some patients find relief through alternative therapies, like acupuncture, where steel needles are inserted into the spine at “acupoints” and the body can release natural chemicals to help with pain.
Typically trigeminal neuralgia can be addressed through medications; however, for some individuals these medications stop working over time or there are significant side effects, and in these cases injections or surgical intervention may be required.
Medications:
Anti-seizure medications: There are a variety of anti-seizure medications that can be prescribed to help address the pain associated with trigeminal neuralgia. Typically, carbamazepine (Brand names: Tergetol, Tegretol XR, Carbatrol, Equetro, Epitol) can relieve the pain. There are a variety of other anti-seizure medications that can be used and it just depends on your symptoms after medication. Please consult your primary care physician or neurologist to determine the ideal anti-seizure medication.
Muscle relaxants: These are often used in conjunction with anti-seizure medications and typically muscle relaxants that are prescribed are Gablofen, Fleqsuvy, and others.
Interventional Pain Management: When medications are ineffective or a tumor is found to be pressing on your nerve, surgery and other interventional procedures may be considered:
Sphenopalatine Ganglion (SPG) Block: A minimally invasive procedure where a small amount of local anesthetic is applied to the sphenopalatine ganglion through the nasal canal.
Gasserian Ganglion Block: Using X-ray imaging, local anesthetic is injected into the gasserian ganglion which blocks it from sending pain signals to the brain.
Stellate Ganglion Block: Bupivacaine, a long-lasting local anesthetic, is injected near the stellate ganglion to block it from sending pain signals to the brain.
Botulinum Toxin Injections: Relaxes facial muscles. Also known as Botox® injections.
Intravenous (IV) Fosphenytoin Therapy: Infusions of special medications are administered intravenously to treat acute attacks of Trigeminal Neuralgia. This procedure takes about 30 minutes to complete.
Spinal Cord Stimulation (SCS): Mainly used for refractory cases of Trigeminal Neuralgia. Small electrodes are placed in the epidural space near the spinal cord and they send electrical current signals that interfere with pain signals.
If medications are not effective, surgical interventions can be pursued. These include:
Brain Stereotactic radiosurgery (Gamma Knife): This is a procedure where a surgeon directs a dose of gamma ray radiation to damage the root of the trigeminal nerve. This radiation gradually helps relieve pain. This is an effective method of stopping pain in most patients; however, there are cases where pain returns and this procedure can be repeated.
Microvascular Decompression: This procedure is done if there is a blood vessel in contact with the trigeminal nerve and it removes these blood vessels to restore normal function to the trigeminal nerve. Most people are pain-free after this procedure for many years.
Peripheral Neurectomy: Surgical removal or cutting of the terminal branches of the trigeminal nerve. This procedure is typically done if other surgical interventions have not worked; however, there is typically a long-term recurrence rate of trigeminal neuralgia after this procedure.
Procedure Videos
V2 nerve block
V3 nerve block
Sphenopalatine Ganglion nerve block
Botox
Radiofrequency Rhizotomy for Trigeminal Neuralgia
References
- Kikkeri, N. S. (2024, March 3). Trigeminal neuralgia. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK554486/
- Hunter, C. (2021, October 4). Trigeminal neuralgia – condition and treatment information. Ainsworth Institute. https://ainsworthinstitute.com/conditions/trigeminal-neuralgia/
- Mayo Foundation for Medical Education and Research. (2023, December 28). Trigeminal neuralgia. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/trigeminal-neuralgia/symptoms-causes/syc-20353344
- What is trigeminal neuralgia?. Cleveland Clinic. (n.d.). https://my.clevelandclinic.org/health/diseases/15671-trigeminal-neuralgia-tn
- Trigeminal neuralgia. NHS inform. (2024, July 11). https://www.nhsinform.scot/illnesses-and-conditions/brain-nerves-and-spinal-cord/trigeminal-neuralgia/
- Diagnosing trigeminal neuralgia. Patient Care at NYU Langone Health. (n.d.). https://nyulangone.org/conditions/trigeminal-neuralgia/diagnosis
- Noro, S., Seo, Y., Honjo, K., Okuma, M., Asayama, B., Amano, Y., Kyono, M., Sako, K., & Nakamura, H. (2021). Intravenous fosphenytoin therapy for rescue of acute trigeminal neuralgia crisis in patients awaiting neurosurgical procedures: A cross-sectional study. Journal of Clinical Neuroscience, 94, 59–64. https://doi.org/10.1016/j.jocn.2021.09.040
- Takei, M., Takizawa, K., Okada, A., otani, N., Noma, N., Otani, N., & Sr., N. N. (2023, December 5). Trigeminal neuralgia with concomitant continuous pain due to vertebrobasilar Dolichoectasia: A case report. Cureus. https://www.cureus.com/articles/204353-trigeminal-neuralgia-with-concomitant-continuous-pain-due-to-vertebrobasilar-dolichoectasia-a-case-report#!/
