Trigeminal Neuralgia

(Tic Douloureux)

The Facts

Trigeminal neuralgia is a condition of recurring pain on one side of the face due to a malfunction of one or more of the three branches of the trigeminal nerve. This nerve is responsible for carrying sensation from the face to the brain. Trigeminal neuralgia is also known as tic douloureux, which means "painful tic."

The term tic is used because people with trigeminal neuralgia often contract their facial muscles, or wince when in pain, because the pain is so severe. Adults of any age can be affected; however, the disorder occurs more frequently as people age, and is more common in people over 50, especially in the elderly. Women are more likely than men to experience trigeminal neuralgia.

The Causes

Trigeminal neuralgia is usually caused by a blood vessel pressing on the nerve inside the skull. Less commonly, multiple sclerosis or a tumour can cause trigeminal neuralgia. In many cases, however, there is no apparent cause.

Symptoms And Complications

Trigeminal neuralgia causes severe, piercing pain (tearing, darting, or sharp cutting sensation) that lasts from several seconds to several minutes. Painful episodes may recur in days, weeks, or months, and periods of remission may grow shorter as you age.

The pain can be excruciating and may be felt in any part of the lower portion of the face - usually in the cheek area near the nose or in the jaw area. Pain may also be felt in the lips, gums, cheek, chin, and sometimes forehead. The pain is usually felt only on one side of the face.

Pain can occur spontaneously or may be set off by touching a particular spot (trigger point) or even by smiling, talking, blowing the nose, brushing the teeth, or chewing.

Although the pain may be incapacitating, it's not life threatening. For some people, the pain is totally incapacitating, recurring as often as 100 times a day. When the pain is triggered by eating, people often lose weight because they are afraid to eat. The pain can be severe enough to wake people from sleep or keep them from sleeping on one side of the face. Other people have a much milder form.

Making A Diagnosis

No specific test is available to identify trigeminal neuralgia. However, the pattern and type of pain associated with trigeminal neuralgia makes it easy to diagnose. The most common cause is a blood vessel compressing the trigeminal nerve inside your head. This can sometimes be seen on an MRI scan. Your doctor will probably want to rule out other possible causes of your pain, such as problems with the jaw, teeth, or sinuses, or compression of the trigeminal nerve by a tumour or aneurysm. This may involve magnetic resonance imaging (MRI) or computed tomography (CT) scans.

Treatment And Prevention

It is important for people with severe trigeminal neuralgia to receive appropriate treatment as quickly as possible, as the pain can interfere with normal activities such as eating and sleeping and can lead to depression and even suicide.

Typical pain medications usually aren't helpful for trigeminal neuralgia because the episodes of pain are related to nerve pain. By stabilizing nerve endings, antiseizure medications (e.g., carbamazepine*, oxcarbazepine, phenytoin, gabapentin) have shown to reduce the number and severity of painful episodes of trigeminal neuralgia. Other medications, such as muscle relaxants (e.g., baclofen) or other types of pain relievers, may also be helpful. Certain antidepressants (e.g., amitriptyline) may also be used.

If the pain cannot be relieved by medications, a surgical procedure to reduce the nerve pain is a possible treatment option. Open surgery to relieve the pressure on the nerve by a blood vessel is effective for most patients. If a person isn't a good candidate for open surgery, a test can be done in which a numbing agent is injected into the nerve and temporarily blocks its function. If the pain is relieved, a balloon or an electrode can be temporarily inserted in the trigeminal ganglion, which is part of the nerve, to produce a mechanical or electrical lesion. This can be very effective at reducing the pain. A lesion of the trigeminal ganglion can also be obtained with focused high dose radiation. This is a well-proven method of treating trigeminal neuralgia. Sometimes, as a last resort for unmanageable pain, the trigeminal nerve is cut or destroyed.