Trigeminal neuralgia

People with trigeminal neuralgia experience severe facial pain. The pain is caused by an irritation of the trigeminal nerve – for example, due to a neighboring blood vessel pressing on the nerve.

The trigeminal nerve is responsible for sending touch and pain sensations from the following parts of the face to the brain:

• forehead and eyes
• upper and lower jaws
• lips and cheeks

The pains are felt on one side of the face. Pain-free phases alternate with periods during which pains recur on a frequent basis.

People with trigeminal neuralgia experience sudden and severe facial pain. The pains mostly occur in the middle and bottom half of the face, especially around the jaw and cheeks.

Pain-free phases alternate with phases of frequent symptoms. The intervals between pain attacks may become shorter over time. People may also experience a continuous dull pain.

Facial pain may be accompanied by a headache. Other possible symptoms are:

• reddened conjunctiva
• contracted pupils
• watery eyes
• a blocked or runny nose
• a swollen eyelid
• a drooping eyelid

In 80% to 90% of people with trigeminal neuralgia, the condition is due to a neighboring blood vessel pressing on the nerve. This irritates the protective sheath covering the nerve, which in turn causes the nerve to be more easily stimulated. Medical professionals refer to this as classic or primary trigeminal neuralgia.

Meanwhile, secondary or symptomatic trigeminal neuralgia refers to cases where the nerve is irritated and facial pain occurs due to other illnesses or conditions.

These include:

• multiple sclerosis
• tumors causing pressure on the nerve
• connective tissue diseases
• congenital deformities of the blood vessels

If no cause can be identified for the facial pains that are typical of trigeminal neuralgia, this is known as idiopathic trigeminal neuralgia.

Attacks of pain may occur randomly or may be triggered by certain irritating factors. These include lightly touching the face, chewing or brushing the teeth. Sometimes, even a cool draft is enough to trigger a pain attack.

People with trigeminal neuralgia often consult a dentist first, as they feel that the pain is coming from the mouth.

In fact, the branch of the trigeminal nerve that provides sensation to the jaw is most often affected.

Trigeminal neuralgia is a rare condition, affecting between 4 and 27 people in every 100,000 per year.

This type of facial pain is somewhat more common among women than men.

Trigeminal neuralgia is a condition in which phases of frequent symptoms alternate with symptom-free periods. It is impossible to predict when an attack may happen.

Some people with trigeminal neuralgia experience daily attacks over weeks and months, followed by a phase in which they have no symptoms at all. Experience indicates that attacks become more frequent as the condition progresses.

Doctors take a detailed medical history and conduct a thorough physical examination to determine whether a patient is suffering from trigeminal neuralgia.

They will ask, for example, how long the pain lasts and how often it occurs. Trigeminal neuralgia may also be indicated by accompanying symptoms and by the triggers that cause the pain attacks.

Doctors also test the sensitivity of the patient’s face and conduct other physical tests. In most cases, this provides enough information to diagnose the condition.

Trigeminal neuralgia can be treated successfully with medication, surgery or radiotherapy.

Conventional painkillers, such as acetylsalicylic acid (ASA), ibuprofen or paracetamol are ineffective for trigeminal neuralgia because the pain attacks are too short. Even the strongest types of pain medication, such as opioids, have no effect.

For prolonged episodes of pain with recurring pain attacks, infusions containing special active ingredients may lessen the symptoms.

It is recommended that patients follow long-term therapy to prevent attacks from occurring. The medications of choice are those that are normally used for epileptic seizures.

The best-known active ingredients are carbamazepine and oxcarbazepine, which reduce the number of painful episodes. The dosage is slowly increased until it is working effectively while causing minimal side effects.

The following treatment options are also available:

• breaking the contact between the nerve and the blood vessel (microvascular decompression)
• destroying the nerve (neuroablation)
• radiation therapy using the Gamma Knife procedure

Surgery is only performed if all other treatment options with the various active ingredients have already been exhausted or cannot be used due to side effects. Microvascular decompression is considered an effective treatment if there is contact between the trigeminal nerve and a blood vessel. The procedure serves to break this contact to relieve pressure on the nerve.

With neuroablation, doctors use heat, pressure or an alcohol solution to destroy the nerve fibers.

Another option is to treat the trigeminal nerve with radioactive radiation (Gamma Knife). This treatment aims to prevent the nerve from sending pain signals to the brain.