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Trigeminal neuralgia

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Also called  as ‘tic douloureux’ or the ‘suicide disease’, trigeminal neuralgia is characterised by intermittent, shooting pain in the face, jaw and eyes. The condition affects the trigeminal nerve, which is the largest cranial nerve and sensory nerve of the head and the face. It is also the motor nerve for the muscles required to chew. The nerve sends impulses of touch, pain, pressure, and temperature to the brain from the face, jaw, gums, forehead, and around the eyes.

Trigeminal neuralgia is often considered one of the most painful conditions in medicine. Usually, the pain is localised to one side of the jaw or cheek, but some people may experience pain on both sides. The pain may last throughout the day or for weeks. It is more common in women than in men and rarely affects people below the age of 50.

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Causes

It is caused when the nerve supply to the face via the trigeminal nerve is obstructed by a blood vessel. This happens because there are small changes in the structure of blood vessels over time, leading them to rub against the trigeminal nerve. The constant rubbing with each heartbeat wears away the insulating membrane of the nerve, resulting in nerve irritation.  In most cases, the blood vessel responsible is the superior cerebellar artery, but in a small portion of cases, it could also be caused by a vein.

Symptoms

This condition is characterised by sudden, severe, electric shock-like, or stabbing pain that lasts several seconds or sometimes for a few minutes. The pain is felt largely on the face but may be localised around the lips, eyes, nose, scalp, and forehead. It can also cause a person’s voice to become hoarse.

Usually the pain is brought on while performing simple functions like while brushing one’s teeth, putting on makeup, touching the face, swallowing, or talking. Studies have shown that even a slight breeze can aggravate the condition.

Diagnosis

Trigeminal neuralgia is a condition that is usually diagnosed based on the patient’s description of his/her symptoms. There are a number of methods including an MRI (Magnetic resonance imaging) or an angioplasty that can be used to rule out other reasons for the pain, but there are no tests to detect the presence of this condition.

Treatment

There are certain medicines that help in reducing the pain and the rate of attacks. They are:


  • Anti-seizure drugs

  • Muscle relaxants

  • Tricyclic antidepressants


If medication does not help, or in some cases if a patient no longer responds to medication, surgery is the only option. The types of surgery that are available are:

  • Cutting or destroying part of the trigeminal nerve

  • Destroying the trigeminal nerve with a needle (probe) passed  through the skin using radiofrequency ablation or an injection of glycerol

  • Electrostimulation: Where the sensitivity of the nerve is reduced using a small electric current

  • Percutaneous balloon microcompression: This is where a small balloon is inserted between the nerve and the offending blood vessel leading to lower pressure on the nerve.

  • Removal of the tumor, if a tumor is the cause

  • Stereotactic radiosurgery (Gamma knife)

  • Surgery to remove a blood vessel that is putting pressure on the trigeminal nerve (called microvascular decompression, or MVD)


In a number of cases, even after surgery, patients tend to experience the pain again after about two years. It is important that they get appropriate postoperative treatment at regular intervals.

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