Medication, Surgery Can Ease Trigeminal Neuralgia Pain

The pain of trigeminal neuralgia is so excruciating, some of its sufferers have called it "the suicide disease." Although it's not fatal, trigeminal neuralgia is widely considered one of the most painful conditions in medical practice. Or, as the National Institute of Neurological Disorders and Stroke (NINDS) puts it, "The intensity of pain can be physically and mentally incapacitating."

Sometimes called tic douloureux - "painful twitch" in French - trigeminal neuralgia (TN) causes episodes of intense, stabbing pain in the face. It can affect the lips, eyes, nose, scalp, forehead and jaw with jolts that can be as severe as an electric shock.

"It's bad," agrees Brian Harris Kopell, MD, an Assistant Professor of Neurosurgery and functional neurosurgeon at the Medical College of Wisconsin. And, he adds, TN is often mentally and emotionally painful for patients' families and friends to witness, helpless to offer their loved one any relief when the episodes occur. Dr. Kopell practices at the Froedtert & Medical College Neuroscience Center.

About 10,000 to 15,000 TN cases are diagnosed every year, or about four or five cases per 100,000 of the population, he says. It's more common among people age 40 and older, and women are slightly more likely to have the condition than men.

Face is Highly Sensitive
TN affects the trigeminal, or fifth cranial nerve, one of the largest nerves in the head. The pain is more intense than other types of nerve pain, Dr. Kopell says, "because the nerves that supply sensation to the face are involved in so many complex functions, so they're highly sensitive."

As described by NINDS, the trigeminal nerve - one of 12 pairs of cranial nerves that originate at the base of the brain - has three branches that conduct sensations from the upper, middle and lower portions of the face and the oral cavity to the brain.

One branch supplies sensation to most of the scalp, forehead and front of the head. The middle branch passes through the cheek, upper jaw, top lip, teeth and gums, and to the side of the nose. The lower branch passes through the lower jaw, teeth, gums and bottom lip. More than one branch can be affected.

TN is thought to be caused in many cases by vascular compression - a blood vessel pressing on the trigeminal nerve in the head as it exits the brainstem, which NINDS says might "be part of the normal aging process." In some cases TM is associated with another disorder, such as multiple sclerosis or other disorder characterized by damage to the myelin sheath that covers certain nerves.

Diagnosing TN
Typically, TN patients are diagnosed by their dentists or primary care physicians or by specialists such as otolaryngologists, whose focus is ear, nose and throat problems. Diagnosis can sometimes be difficult, Dr. Kopell says, because symptoms of facial pain can occur with other conditions.

"The first line of treatment for TN is medication, absolutely," Dr. Kopell says. According to NINDS, "some patients choose to manage TN using complementary techniques, usually in combination with drug treatment. These techniques might include acupuncture, biofeedback, vitamin therapy, nutritional therapy and electrical stimulation of the nerves."

Most TN patients experience some relief from appropriate drug therapy, including Tegretol or other anti-convulsant drugs. Anti-convulsants, which block nerve firing, are generally effective in treating TN.

Surgery Sometimes Indicated
For those patients who have tried medications for six months or more without success, however, inpatient or outpatient surgery might be indicated, Dr. Kopell says. As a neurosurgeon, he generally doesn't treat TN patients unless medication and other treatments used consistently have failed to provide relief.

According to NINDS, the type of surgery "depends on the patient's preference, physical well-being, previous surgeries, presence of multiple sclerosis, and area of trigeminal nerve involvement, particularly when the upper trigeminal branch is involved."

The gold standard among surgical options is microvascular decompression, Dr. Kopell says. "It's good option for younger patients and has the best statistics for a good, long-term outcome." Microvascular decompression is the most invasive of all surgeries for TN, but it also offers the lowest probability that pain will return, NINDS says.

This open-brain inpatient procedure, performed under general anesthesia, requires that a small opening be made behind the ear. While viewing the trigeminal nerve through a microscope, the surgeon moves away the vessels that are compressing the nerve and places a soft cushion between the nerve and the vessels. Patients generally recuperate for several days in the hospital after the procedure.

Other surgical options Dr. Kopell uses include an outpatient procedure called percutaneous radiofrequency trigeminal gangliolysis. With this method, while the patient is sedated, the surgeon inserts a needle through the cheek and, guided by X-ray, injects a radiofrequency current into the ganglion, a cystlike tissue mass thought to be responsible for the pain. The current heats and destroys selected portions of the ganglion. This procedure may be used especially to treat older patients and others who are not considered candidates for microvascular decompression. Although it provides relief in almost all patients, it does have a recurrence rate of 20% to 30%.

Another outpatient procedure Dr. Kopell uses for treating patients who are not good candidates for conventional surgery is gamma knife. Despite its name, gamma knife is not a knife but a helmet-like device through which patients receive highly focused beams of radiation that destroy lesions but spare healthy tissue. It is used for a variety of brain surgeries.

In addition to treating patients, Dr. Kopell and his colleagues at Froedtert and the Medical College are currently doing research into why TN and other conditions marked by neuropathic pain occurs.

"No one should have to live with such excruciating pain that occurs with trigeminal neuralgia," he says. "Medication provides relief for many patients, and for others, we can offer many other options including both inpatient and outpatient surgical procedures."

Barbara Abel
HealthLink Contributing Writer

This article includes information from the National Institute of Neurological Disorders and Stroke.

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