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Trigeminal Neuralgia (Facial Pain)

Overview
Causes
Symptoms
Diagnosis
Treatment Options
Where To Seek Treatment
National Neuroscience Institute
Contributed by Dept of Neurosurgery

Overview

Trigeminal neuralgia (Facial Pain) is characterised by brief episodes of intense, stabbing, electric shock-like facial pain. These episodes occur spontaneously or can be triggered by light touch, chewing, or changes in temperature (i.e. cold). The pain is so intense as to be completely disabling. In addition, weight loss is common because oral triggers prevent affected individuals from eating enough to maintain adequate nutrition.

A less common form of the disorder, called "Atypical Trigeminal Neuralgia", may cause less intense, constant, dull burning or aching pain, sometimes with occasional electric shock-like stabs.


Causes

The cause of this condition is irritation of the fifth cranial nerve (the Trigeminal nerve) which is responsible for providing facial sensation. This irritation is occasionally due to benign tumours or multiple sclerosis, either of which can usually be detected by a high quality MRI of the brain.

In the majority of cases, however, imaging of the brain does not reveal a cause of the nerve irritation. In such cases a small vessel (usually an artery but occasionally a vein) is often found at operation to be compressing the root entry zone of the Trigeminal nerve at the brainstem.


Symptoms

The pain, which comes and goes, feels like bursts of sharp, stabbing, electrical shocks involving the cheek, nose, upper lip or the jaw. In almost all cases (more than 95%), pain will be restricted to one side of your face. This pain can last from a few seconds to a few minutes. Common daily activities such as eating, drinking or brushing the teeth can bring on the pain.


Diagnosis

If you show symptoms trigeminal neuralgia, you should see a doctor to confirm the diagnosis. Your doctor will conduct an interview and physical examination, and may ask you specific questions regarding the pain – including onset, nature and triggering factors. He may also arrange for you to have a magnetic resonance imaging (MRI) of the brain.

You may be referred to a neurosurgeon if deemed necessary.


Treatment Options

Trigeminal neuralgia is an eminently treatable condition.

The first line of therapy consists of medications such as Carbamazepine and Gabapetin. In most cases, medical treatment is effective.

If medical treatment fails or is limited by significant side effects, we have good surgical options for patients with trigeminal neuralgia. Surgery is usually ineffective for atypical trigeminal neuralgia.

Surgical Options

Microvascular Decompression - surgery through the skull, which removes or insulates the responsible blood vessel(s) using microsurgery - is an effective method of treating many people with this disorder. This is done under general anaesthesia. After the operation, the majority of patients have no facial numbness and are pain-free, requiring no further medications. It is a major operation, and is not without danger. Most of the serious and life-threatening complications have occurred in patients above 65-70 years of age. It is less effective for patients who have had other operations in the past.

Percutaneous Radiofrequency Gangliotomy uses a special needle inserted in the face and radiofrequency-generated heat energy to selectively damage the preganglionic trigeminal rootlets in Meckel's cave. It is carried out in the awake patient and requires his co-operation and accurate feedback for proper positioning of the needle. It causes irreversible facial numbness. Precise control of the extent of the lesion is not always possible. Abnormal, unpleasant sensations of itching, burning or crawling (20% patients) can accompany facial numbness. When severe (0.3%), they are as distressing to the patient as their original pain, since they can be present continuously as a severe burning discomfort (anaesthesia dolorosa or analgesia dolorosa) which does not respond to treatment. Loss of feeling in the first Trigeminal division makes the cornea insensate, and leaves the patient at risk for corneal ulceration and can lead to loss of vision.

Percutaneous Glycerol Chemoneurolysis is also carried out using a needle inserted in the face and can be performed under general anaesthesia. There is usually only mild sensory loss and rare oculomotor or dysesthetic sequelae. Of course, it has the same risks of meningitis and needle misdirection injury as any percutaneous technique. Compared with radiofrequency gangliotomy, the pain recurrence rate is higher, but this is not a significant disadvantage, as the procedure can be easily repeated and is well tolerated.

Gamma Knife Radiosurgery i.e. radiation treatment performed without opening the skull, using intense gamma rays directed at the Trigeminal nerve root, has been carried out recently. However long-term data comparable to that reported for other procedures is lacking. Reports so far have considered 50-90% reduction of pain as good and 10-50% as fair. No pathologic data is available regarding the immediate and long-term effects of high dose radiation (70-90 gy) to the nerve adjacent to the brain stem.

The choice of operation depends on the patient's age, associated illness and assessment of the risks he is willing to assume. For most "younger" patients, microvascular decompression is the best option. Younger patients have a better chance of tolerating surgery without complications, and a longer future life expectancy in which to deal with problems that can follow percutaneous lesioning. They also have a higher risk of pain recurrence following such procedures and will likely need more future treatments resulting in an increased cumulative side-effects.

Older patients (>65-70 years of age) have increased risks of surgical complications. But because of shorter overall life expectancy, they likely will require fewer repetitions of percutaneous procedures with less cumulative denervation sequelae. Significant associated illness such as chronic obstructive pulmonary disease, coronary artery disease and diabetes mellitus can also increase the risks of such major surgery.


Need indepth information ?

Access our Conditions & Treatments sections for related topics on Chronic Obstructive Pulmonary Disease, Coronary Artery Disease and Diabetes Mellitus.


Where to Seek Treatment

The medical institutions within SingHealth that offer consultation and treatment for this condition include:

1. National Neuroscience Institute - Singapore General Hospital Campus
Dept of Neurosurgery
Outram Road, Singapore 169608

Appointments Hotline:
Tel : +65 6321 4377

International Enquiries, please contact:
Tel : +65 6326 5656
Email : ims@singhealth.com.sg
   
2. National Neuroscience Institute - Tan Tock Seng Hospital Campus
Dept of Neurosurgery
11 Jalan Tan Tock Seng, Singapore 308433

Appointments Hotline:
Tel : +65 6357 7095

International Enquiries, please contact:
Tel : +65 6326 5656
Email : ims@singhealth.com.sg





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