Trigeminal Neuralgia

Trigeminal neuralgia is a chronic condition that causes intense facial pain, usually down one side of the face. It most commonly develops in those over 50, particularly women, but it can occur in younger people and men as well.
Trigeminal neuralgia is not life-threatening, but the pain variously described as burning, stabbing, or like an electric shock can be severe enough to cause physical and emotional distress.
The source of the pain is the trigeminal nerve, also known as the fifth cranial nerve, or CNV. The trigeminal nerve transmits signals between the brain and the face, eyes, and teeth as well as the muscles that control chewing. There are two trigeminal nerves, one on each side of the face, and each has three branches: the ophthalmic nerve, the maxillary nerve, and the mandibular nerve. Trigeminal neuralgia can affect any of these three, but is most commonly a condition of the maxillary and mandibular nerves.
Episodes of trigeminal neuralgia may be spontaneous, or they may be triggered by mild stimulation of the face. Over time, the attacks can grow in duration, intensity, and frequency.
In most patients, most of the pain comes in sudden, sharp bursts — this is considered Type 1 trigeminal neuralgia. In others, the pain is more continuous and is described as aching or burning, with sharp bursts of pain occurring intermittently — this is considered Type 2 trigeminal neuralgia. The treatment is the same regardless of the type.
Symptoms of Trigeminal Neuralgia
Trigeminal neuralgia may produce many different symptoms including:
  • Excruciating, stabbing pain of the face or jaw, which can feel like an electrical shock.
  • Numbness, tingling, or a burning sensation on one side of the face.
  • Facial pain accompanied by a muscle spasm, or “tic.”
  • Face or jaw pain that is triggered by simple, everyday acts such as shaving, applying make-up, brushing teeth, chewing, talking, and touching the face.
  • Pain that is isolated to one side of the face, including the jaw, cheek, gums, mouth, and sometimes the forehead and eye.
  • Pain that is concentrated in one small area — or alternatively, spread over a large area of the face.
  • Attacks of pain that can last for a few seconds up to several minutes.
  • Repeated episodes that can last for days, weeks, months, or longer.
  • Episodes that increase in intensity, duration, and frequency.
Your doctor will diagnose trigeminal neuralgia mainly based on your description of the pain, including:
  • Pain related to trigeminal neuralgia is sudden, shock-like and brief.
  • The parts of your face that are affected by pain will tell your doctor if the trigeminal nerve is involved.
  • Trigeminal neuralgia-related pain usually is brought on by eating, talking, light touch of your face or even encountering a cool breeze.
  • A neurological examination.Touching and examining parts of your face can help your doctor determine exactly where the pain is occurring and — if you appear to have trigeminal neuralgia — which branches of the trigeminal nerve may be affected. Reflex tests also can help your doctor determine if your symptoms are caused by a compressed nerve or another condition.
  • Magnetic resonance imaging (MRI).Your doctor may order an MRI scan of your head to determine if multiple sclerosis or a tumor is causing trigeminal neuralgia. In some cases, your doctor may inject a dye into a blood vessel to view the arteries and veins and highlight blood flow.
Surgery for Trigeminal Neuralgia
Surgery may be an option for treating trigeminal neuralgia when the diagnosis is confirmed with an MRI scan or other neuro-imaging, and when less invasive options have been exhausted.
The goal of surgery is to either stop a blood vessel from compressing the trigeminal nerve, or to sever the nerve that’s causing the pain. There are various types of surgeries — a neurosurgeon will consider the individual case before recommending the approach most likely to provide relief.
The various surgical options include:

Microvascular Decompression (MVD)
Microvascular decompression is an open surgical procedure that involves moving or removing the blood vessels that are creating pressure on the trigeminal nerve. The neurosurgeon will make an incision behind the ear on the side that is causing pain, exposing the trigeminal nerve, then removes or relocates any blood vessels that are compressing the nerve or inserts a small pad to prevent contact with the nerve. If no blood vessels are compressing the nerve, the surgeon will conduct a rhizotomy to sever the nerve itself.

Stereotactic Radiofrequency Lesion (RFL)
Stereotactic radiofrequency lesion (RFL) is a less invasive procedure than microvascular decompression. A radiologist and neurosurgeon collaborate to pinpoint the exact location of the nerve, then use high heat to destroy only the pain portions of the trigeminal nerve, leaving other sensation intact. Pain relief is usually immediate (or within 48 hours); in some patients the procedure may be repeated several times until adequate pain relief is achieved. 

Stereotactic Radiosurgery
Stereotactic radiosurgery is not surgery in the conventional sense, but rather a non-invasive specialty that does not involve any cutting at all. It consists of directing beams of highly focused radiation at a specific target in this case, the trigeminal nerve.  The radiation beam damages the trigeminal nerve, but does not destroy it completely. Pain relief occurs gradually, over the course of a few weeks. The results are usually long-lasting, and the treatment can be repeated in the case of recurrence. The GammaKnife is one type of stereotactic radiosurgery treatment it’s a completely painless, highly effective treatment that can be performed on an outpatient basis. 

Neurostimulation On occasion, patients with typical trigeminal neuralgia will not respond to any or all of these treatments, or their pain recurs after an initially good response. Some patients may have symptoms similar to trigeminal neuralgia, but rather than short recurring spasms of pain they have more chronic, burning pain, suggesting a problem with the nerve that is different than typical trigeminal neuralgia. Patients can also have facial pain due to injuries or surgery, which does not respond well to medication. For all of these, neurostimulation can be considered.
Neurostimulation is a minimally invasive procedure in which a neurosurgeon places a small wire under the skin touching one or more branches of the nerve in the painful part of the face. The patient controls a device that can turn on a current to the wire. The device is tested for several days; the patient turns the stimulator device on to generate a buzzing or massage-type sensation, which is often pleasant and blocks the pain signal from getting to the brain. If a patient experiences good results from the test, the neurosurgeon can implant a permanent stimulator with a battery pack under the skin. The patient can control the device wirelessly, turning it on or off and changing the intensity of stimulation. The choice of surgical treatment depends on the individual patient the neurosurgeon will evaluate each case carefully before recommending a treatment option.