Trigeminal neuralgia-also known as tic douloureux is a painful disorder of one or more branches of the fifth cranial (trigeminal) nerve. This nerve affects chewing movements and sensations of the face, scalp, and teeth. On stimulation of a trigger zone, the patient experiences paroxysmal attacks of excruciating facial pain, probably produced by an interaction or shortcircuiting of touch and pain fibers.

The disease occurs mostly in people over age 40 (about 25% more women than men) and on the right side of the face more often than the left. Trigeminal neuralgia can subside spontaneously, with remissions lasting from several months to years.

Causes of Trigeminal Neuralgia

Although the cause remains unknown, trigeminal neuralgia may reflect an afferent reflex phenomenon located centrally in the brain stem or more peripherally in the sensory root of the trigeminal nerve. Such neuralgia may also be related to compression of the nerve root by posterior fossa tumors, middle fossa tumors, or vascular lesions, although such lesions usually produce simultaneous loss of sensation. Occasionally, trigeminal neuralgia results from multiple sclerosis or herpes zoster.

Signs & Symptoms of Trigeminal Neuralgia

An attack of trigeminal neuralgia can last from a few seconds to about a minute. Some people have mild, occasional twinges of pain, while other people have frequent, severe, electric-shock-like pain. The condition tends to come and go. You may experience attacks of pain off and on all day, or even for days or weeks at a time. Then, you may experience no pain for a prolonged period of time.

The attacks often worsen over time, with fewer and shorter pain-free periods before they recur. The intense flashes of pain can be triggered by vibration or contact with the cheek (such as when shaving, washing the face, or applying makeup), brushing teeth, eating, drinking, talking, or being exposed to the wind.

Diagnostic Tests

Diagnosis is usually made by eliminating other problems that could cause similar pain in teeth, jaw, head, or sinuses. Because patients with the condition tend to avoid trigger points, avoiding chewing, shaving, touching or washing their faces can be a clue to diagnosis of trigeminal neuralgia.

Treatment

Oral administration of carbamazepine or phenytoin may temporarily relieve or prevent pain because they reduce the transmission of nerve impulses at affected nerve terminals. Narcotics may be helpful during the acute pain episode.

Before surgery is performed, non-surgical treatment-injecting small amounts of glycerol into the subarachnoid space-may be tried. If this treatment fails, the procedure of choice is percutaneous electrocoagulation of nerve rootlets under local anesthesia. An alternative is a percutaneous radio frequency procedure, which causes partial root destruction and relieves pain. One to three treatments are usually necessary. The procedure causes partial numbness of the face.

Microsurgery for vascular decompression of the trigeminal nerve involves an intracranial approach. This major procedure requires postoperative management similar to that for craniotomy. Its advantage is that it preserves normal sensation in the face.

Radiosurgery is another option in which a stereotactic technique is used. The nerve root is localized, and focused high-dose radiation is delivered. It's done as an outpatient technique and is a knifeless surgery. The focused radiation allows for interruption of the nerve without damage to the surrounding tissue.

Prevention Tips

While the condition itself can't be prevented, there are a number of things patients can do to avoid triggering attacks:

Wash your face with warm water.
Rinse the mouth with water after eating, if toothbrushing triggers pain.
Eat food and drink beverages at room temperature.
Eat soft foods, if eating is becoming a problem.

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