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Case Studies in Headache Archive: Treating Trigeminal Neuralgia

By Edmund Messina, MD, Medical Director of the Michigan Headache Clinic in East Lansing, Michigan

While headaches are typically thought to be located around the forehead or back of the head, there are types of headache that strike the face itself. Trigeminal neuralgia is a form of severe facial pain in which patients experience brief volleys of very painful electric shock sensations triggered by mild touch to the face or mouth. This touch can be from washing, shaving, eating, brushing the teeth or even talking. The trigger zones are particularly sensitive in the area between the nose and mouth or on the chin.

Trigeminal neuralgia is also sometimes called “tic douloureux.” This French term describes the muscle spasm caused by the nerve pain, sort of a one sided-grimace. The pain begins and ends suddenly, lasting from a fraction of a second to up to two minutes. The attacks can occur several times a day and may go on for weeks or months at a time before going into remission. The pain of trigeminal neuralgia is so severe that patients fear its return. Untreated patients may even experience malnutrition because eating is so painful.

Trigeminal neuralgia is commonly misdiagnosed as a dental problem, leading to inappropriate extractions in desperate patients. Because there are rare headache conditions and other types of cranial neuralgia that may imitate many of the symptoms, it is best to be evaluated by a headache specialist. Patients with trigeminal neuralgia usually have normal neurological examinations, except for the trigger zones.

Though not well known, trigeminal neuralgia is not a rare condition—approximately 15,000 new cases of trigeminal neuralgia are diagnosed each year. It is more common in people over age 40.

The condition is believed to be due to a compression of a branch of the fifth cranial nerve, which carries pain and sensation from the face, ears, eyes and teeth. This compression is usually caused by a looped blood vessel touching the base of the nerve. In younger people, however, it can be caused by multiple sclerosis, tumors or aneurysms. For this reason, imaging studies such as MRI (magnetic resonance imaging) and MRA (magnetic resonance angiogram) are necessary. CT scans are much less useful in this condition. The term “symptomatic trigeminal neuralgia” means that a cause other than vascular compression has been found on testing.

Treating Trigeminal Neuralgia

Carbamazepine (Tegretol®, Carbatrol®) is the first-line agent used by most healthcare professionals who treat trigeminal neuralgia. The dose is tapered and adjusted to the needs of the individual patient. This medication should be monitored with blood tests, since it could affect the blood count. Most people respond to carbamazepine, while others prefer phenytoin (Dilantin®). Baclofen may also be added or used by itself. In more recent years, oxcarbazepine (Trileptal®) has become popular in the treatment of trigeminal neuralgia and it, too, is a very effective agent. Some people need to be treated mainly during colder months, when they are more vulnerable.

When patients do not respond adequately to medications or do not tolerate the effective doses, surgical solutions may be offered. The longest lasting results are usually obtained through a neurosurgical technique known as microvascular decompression. This involves opening the skull and placing synthetic material between the nerve and the compressing blood vessel. Success rates are high and recurrence rates are low. It is particularly useful in younger patients.

In more recent years, Gamma knife radiosurgery has become a very popular treatment for older patients. It focuses a precise beam of radiation on the entry zone of the trigeminal nerve. CyberKnife™ is similar, but less precise, and multiple visits are needed, although it is a simpler procedure. These two techniques are noninvasive and often very successful. However, it may take months to see significant reduction of pain and the pain can reoccur over months or years.

Trigeminal neuralgia can generally be controlled by medication or neurosurgical techniques, but it is important to separate it from other conditions. If you or someone you know has similar symptoms, seek an expert opinion!

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