Trigeminal neuralgia

Symptoms Of Trigeminal Neuralgia 

The significant symptoms of trigeminal neuralgia include: 

• A sudden attack of severe, sharp, shooting pain that lasts for a few seconds to a few minutes.

• The pain is often described as an electric shock-like, burning, pressing, crushing, exploding, shooting, migraine-like, piercing, prickling, or a combination.

• The pain is usually felt in the teeth, lower jaw, upper jaw, or cheek. The right side of the face is more often affected than the left side.

• Usually, the pain resolves completely between the attacks. This is known as a refractory period.

• Attacks are generally stereotyped or of the same pattern in an individual patient.

• In severe cases of TN, attacks may happen hundreds of times a day, and in some instances, there may be no periods of remission.

Note: Trigeminal neuralgia is also called tic douloureux because extreme pain can cause patients to make a face and move their heads away from the pain. This movement is also referred to as a tic.

The activities that can trigger the symptoms of TN are:

• Light touch

• Washing the face 

• Shaving 

• Head movements 

• Swallowing 

• Chewing 

• Smiling 

• Talking

• A cool breeze against the face

• Traveling in a car 

Causes Of Trigeminal Neuralgia 

Trigeminal neuralgia is caused by compression of the trigeminal nerve, which is the largest nerve inside the skull. This nerve conducts the sensation of pain and touch from teeth, face, and mouth to the brain.

Primary Trigeminal Neuralgia 

Primary trigeminal neuralgia is caused by the compression of the trigeminal nerve at the base of the head where it enters the brain stem (the lowest part of the brain). In most cases, the pressure is caused by an artery or vein compressing the trigeminal nerve.

In some cases, the pressure on the nerve wears away its protective outer layer (myelin sheath), which may cause pain signals to travel along the nerve. 

Secondary Trigeminal Neuralgia 

Secondary TN is when neuralgia is caused by another medical condition or disease. For example: 

• Cysts 

• Tumor 

• Facial injury 

• Damage caused by the surgery 

• Viral infections like shingles, chickenpox, and herpes

Risk Factors For Trigeminal Neuralgia 

Most often, the cause of trigeminal neuralgia is idiopathic, i.e. the exact cause is not known. However, the following risk factors can increase the chances of developing trigeminal neuralgia:

Age 

The risk of TN increases with age. It is higher in individuals between the ages of 50 and 60 years. This is because as one ages the blood vessels harden and brain sags, which leads to the formation of new contacts between nerves and blood vessels. 

Sex 

Women are more likely to develop trigeminal neuralgia than men.

Systemic conditions

• Multiple sclerosis: Multiple sclerosis is a significant risk factor for TN. It is an autoimmune disease that affects the protective myelin sheath of the body's nerves, predisposing to trigeminal neuralgia.

• Diabetes: Diabetes can increase the risk of developing trigeminal neuralgia, possibly due to nerve damage caused by hyperglycemia (high blood glucose).

• Sarcoidosis: It is a disease characterized by the growth of small collections of inflammatory cells (granulomas) in any part of your body. It has been occasionally associated with trigeminal neuralgia. 

• Lyme disease: It is an infection that happens when an infected tick bites a human. Rarely, this systemic inflammatory condition can increase the risk of trigeminal neuralgia.

• Scleroderma: It is also known as systemic sclerosis, a group of rare diseases that involve the hardening and tightening of the skin. Some people with scleroderma have higher chances of developing trigeminal neuralgia.

• Systemic lupus erythematosus (SLE): SLE is an autoimmune disease in which the immune system attacks its own tissues, causing widespread inflammation. In some rare cases of SLE, the immune system tends to attack the trigeminal nerve and lead to TN.

Diagnosis Of Trigeminal Neuralgia 

The doctor may consider the following methods to diagnose TN:

Medical history and physical examination

For the diagnosis of trigeminal neuralgia, a complete physical examination and a detailed medical history is required to rule out other causes of facial pain. The medical practitioner will ask about:

• Intensity of pain attacks 

• Duration of pain attacks 

• Affected areas of the face 

There's no specific test for TN; therefore, its diagnosis is usually based on the individual’s symptoms and description of the pain.

An important aspect of diagnosing trigeminal neuralgia involves ruling out other conditions that lead to facial pain like:

• Joint pain in the lower jaw

• Toothache

• Nerve injury 

• Migraine (a headache that can cause severe throbbing pain or a pulsing sensation, usually on one side of the head)

Imaging Techniques 

• Magnetic Resonance Imaging (MRI):  This test helps in diagnosing the possible cause of facial pain, such as inflammation of the lining of the sinuses, nerve damage caused due to MS, and tumor on facial nerves. An MRI scan can also detect whether a blood vessel is compressing one of the trigeminal nerves. 

• Computed Tomography (CT) scan (head): Computed tomography (CT) of the head uses special x-ray equipment to help assess and identify tumors or multiple sclerosis, which can cause secondary TN.

Prevention Of Trigeminal Neuralgia 

Trigeminal neuralgia is not preventable.

But certain triggering factors can be avoided by taking necessary precautions: 

• Wind: If the wind is a trigger, a scarf can be worn around the face to protect against it. 

• Cold drinks: A straw can be used to drink cold water or drinks. This will prevent the liquid from coming in direct contact with the painful areas.

• Chewing: Liquidize the meals if you find it difficult to chew the food.

• Avoid certain foods: Some foods seem to trigger attacks. It is better to avoid food items like citrus fruits, bananas, and caffeine.

Correct diagnosis and proper management also benefit the patients and lead to a good prognosis. 

Specialist To Visit

The best doctor to visit in case of severe and sharp pain in the face is: 

• Neurologist

A neurologist helps in the proper diagnosis and treatment of diseases of the brain and nervous system. 

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Treatment Of Trigeminal Neuralgia 

Management of TN depends on multiple factors, including age, general health, disease severity, and other medical conditions. Medicines can be used to control the pain, or surgery may be considered where drugs have been ineffective for the long term. 

Medications

• The first-line treatment for patients with TN is pharmacologic therapy. Painkillers like paracetamol are not effective; therefore, an anticonvulsant is prescribed for the treatment. 

• The most commonly used anticonvulsant drug is carbamazepine. This medicine is usually started at a lower dose and gradually increased to control the pain. The pain is controlled for most people in the early stages of the disease. However, in some patients, the effectiveness of carbamazepine decreases over time.

• Another anticonvulsant drug gabapentin, which is most commonly used to treat epilepsy or migraines, can also treat TN.

• Other medicines used to treat trigeminal neuralgia include oxcarbazepine, baclofen, and pregabalin. 

Percutaneous procedure

Percutaneous procedures are performed through the smallest possible working incision, by inserting a needle or thin tube through the cheek and into the trigeminal nerve inside the skull. X-rays of the head and neck are usually performed to help guide the needle into the correct place. 

The various percutaneous procedures to treat trigeminal neuralgia are:

Radiofrequency lesioning (Rhizotomy)

Rhizotomy provides pain relief to approximately 80% of patients with TN, but it’s a temporary solution that usually lasts 1-3 years until the nerve regrows. The surgeon inserts a long needle through the cheek on the affected side of the face and uses heat or a chemical to suppress the pain fibers of the trigeminal nerve.

Glycerol injections

It involves the injection of a small amount of glycerol into the trigeminal nerve to block pain signals to the brain. This method is mostly used in patients who are immunocompromised by other chronic diseases. 

Balloon compression 

The surgeon will insert a tube, called a cannula, through your cheek up to the trigeminal nerve. A thin, flexible tube with a balloon on one end is then weaved through the needle. This procedure has been known to relieve symptoms for 1-2 years, though it can cause some numbness in the face.

Surgery 

Microvascular decompression (MVD)

This is one of the most surgical common procedures used to treat trigeminal neuralgia. It can help relieve pain without intentionally damaging the trigeminal nerve. This surgery reveals the blood vessel that may be compressing the nerve and provides the longest relief from trigeminal neuralgia.

Stereotactic radiosurgery

This procedure delivers a highly concentrated and precise beam of radiation on the trigeminal nerve root to relieve the pain. It’s always recommended that patients receive it no more than two times as a treatment for trigeminal neuralgia.

Alternative Therapies of Trigeminal Neuralgia 

Acupuncture 

Acupuncture involves the insertion of thin needles along the “trigger points” to provide pain relief. Some precautions must be taken while inserting the acupuncture needles to avoid coming into contact with trigger areas, as this may flare up the symptoms.

Meditation

Meditation therapy can help in alleviating the pain caused by Trigeminal neuralgia. This technique helps slow breathing and relax, which helps ease or prevent stimulation of the trigeminal nerve. 

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Aromatherapy

Essential oils of chamomile and lavender can help ease neuropathic discomfort. This therapy does not work for everyone, although for some it can provide relief from the pain of TN.

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Complications Of Trigeminal Neuralgia 

• The pain in Trigeminal Neuralgia can be so severe and exhausting that the patients can develop anxiety and depression, if not properly treated.

• Patients treated with anticonvulsant drugs for the long term can have unfavorable drug effects.

• Some patients permanently develop facial numbness on the affected side.

• The surgical procedures for treatment can pose some intra and postoperative risks.

Living With Trigeminal Neuralgia

Although Trigeminal Neuralgia is not fatal, it causes pain and anxiety, which can ultimately affect the patient's quality of life. A person may find themselves feeling overwhelmed and isolated at times. Caring for mental health, connecting with others, and practicing self-care can all go a long way in preserving the quality of life. Here are a few steps to follow while living with this condition: 

Look after mental health 

The chronic repetitive and unpredictable shots of stabbing pain can leave people isolated and vulnerable to depression and anxiety, and in some extreme cases, even suicidal thoughts can emerge. Participating in social interactions and engaging in small household work can help divert the mind. 

Avoid triggers 

While the TN pain attacks are often spontaneous, some people with TN find specific triggers that bring on their pain attacks. Some common triggers include spicy foods, cold beverages, and chewing. If a person finds out his triggers, a conscious effort to avoid them may help alleviate TN pain.

Practice a healthy lifestyle and general self-care

Looking after your overall health through a balanced diet, regular exercise, a consistent sleep schedule, and mental healthcare is crucial. Managing TN is much easier when the rest of the body is cared for by leading a healthy life. 

If your loved one has Trigeminal neuralgia, the following pointers can help you extend a helping hand to the patient:

• Understanding the severity of the pain the person is going through and being accommodating are the first steps to caring for a loved one with trigeminal neuralgia. 

• Helping your loved one stay on track with their medications and communicating about the success of the treatment.

• Encouraging doctor visits and exploring other treatment options when medications stop working.

Home Care For Trigeminal Neuralgia 

There are no highly effective home remedies for trigeminal neuralgia. However, you can try the following after consent from your doctor. They will act as an adjunct to conventional medical treatment:

Hot or cold compression

Taking a hot shower or bath can help relieve the symptoms. Cold compressions, like ice or cold water, can also help relieve painful episodes.

Peppermint 

It is used as a pain reliever and helps in relaxing the muscles to control muscle spasms. Peppermint oil can be used alone, by combining it with a carrier oil to minimize pain and irritation caused by trigeminal neuralgia.

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Basil (Tulsi)

It is an effective herb that has been used for over 3000 years due to its incredible healing powers. It acts as a stress regulator and inhibits nerve pain in case of trigeminal neuralgia. Essential oil of basil can be applied to the affected area to get instant relief.

Dietary supplements

The addition of vitamins B12 and minerals in the diet can help in alleviating the discomforting trigeminal neuralgia symptoms. 

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