02 Nov Case Studies in Headache: Trigeminal Neuralgia
By David M. Biondi, D.O.
Director, Headache Management Program, Spaulding Rehabilitation Hospital and Instructor in Neurology, Harvard Medical School
James is a 65-year-old man who woke one day with severe pain on the right side of his face. The pain, which seemed to tear through his face like a lightning bolt, lasted only a few seconds, but then returned. For weeks, he had been experiencing dozens of these excruciating electrical shock-like attacks. James could no longer shave the right side of his face, brush his teeth, chew foods or talk for any length of time without triggering the repeated jolts of pain. He could not even tolerate a light breeze blowing across his face. James’ dentist could find no problems with his teeth or jaw and over-the-counter pain relievers provided no benefit.
James has a condition called trigeminal neuralgia, also known as tic douloureux, which is one of several facial neuralgias. Neuralgia is a type of pain that is caused by nerve injury or irritation.
The trigeminal nerve provides all sensation, including pain, to the face, teeth, mouth, sinuses, meninges (coverings of the brain) and blood vessels of the head. There are two trigeminal nerves, one on each side of the head, and each has three branches supplying the upper, middle and lower parts of the face. The pain of trigeminal neuralgia is felt in the territory of one or more branches of this nerve. Most commonly, it affects the middle part of the face and upper teeth. Trigeminal neuralgia almost always occurs on one side of the face, but in rare cases it can affect both sides at the same time.
The pain of trigeminal neuralgia is severe and, as James described, sharp, jolting and shock-like. The duration of each painful jab is very brief, lasting only seconds, but people with trigeminal neuralgia have numerous attacks each day, sometimes hundreds. A longer-lasting deep, burning or dull pain may persist in between the lightening-like jolts of episodic pain. The pain can be triggered by chewing, talking, shaving, brushing teeth, light touch, cold air or wind blowing on the face. Remissions lasting weeks or months can occur, but the pain usually returns.
Trigeminal neuralgia most commonly affects people over 60 years old, but may begin at any age. Many cases of trigeminal neuralgia have no easily identifiable cause. When trigeminal neuralgia occurs in a young person, multiple sclerosis or other diseases of the nerves can be possible causes. A traumatic injury to the face or problems with the teeth can also cause trigeminal neuralgia. It can sometimes occur after dental work or a tooth extraction. Some cases are believed to occur deep in the skull as a result of pressure placed on the trigeminal nerve by one or more blood vessels.
The intense pain of trigeminal neuralgia is disabling because it occurs frequently and rapidly without warning. People who have this condition may become depressed and frustrated, and live in fear of the next attack. They will often avoid washing, eating, or talking because even these normal activities of daily living can trigger the pain.
Fortunately, there are many medical, anesthetic and surgical treatment options available for the management of trigeminal neuralgia. Some of the medications that might be prescribed alone or in combination to control trigeminal neuralgia pain are carbamazepine, phenytoin, baclofen, divalproex sodium, gabapentin, amitriptyline, and clonazepam. Other medications are also available. Pain relieving procedures include anesthetic or neurolytic trigeminal nerve blocks (blocking pain signals that are coming from the trigeminal nerve), radiofrequency thermal neurolysis (using a focused microwave to heat certain portions of the trigeminal nerve as a way to partially block its ability to carry pain signals), and gamma knife radiosurgery (using a focused radiation beam to heat the root of the trigeminal nerve). While these procedures may only provide partial or temporary pain relief in some cases, they can improve responsiveness to medications. Cases of trigeminal neuralgia that do not respond to these less invasive treatments may need surgery to expose and remove or cushion blood vessels that may be compressing the trigeminal nerve.