Facial Pain: The Agony of Trigeminal Neuralgia

The pain begins suddenly and occurs unpredictably. It has been variously described as an electrical sensation extending into the face or as if someone is stabbing one in the face. It can be triggered by simple daily activities such as brushing the teeth, chewing, swallowing, washing the face, shaving, or even going outside in a heavy wind. The pain can even strike without any aggravating event at all. This is the pain of trigeminal neuralgia, once known as tic douloureux.

It is a pain that was described originally in medical literature at least 300 years ago but has become much better understood within the last century. Treatment of the pain has also become much more effective. Prior to the last 50 years, and before effective treatment was available, the pain could become so severe that patients often considered suicide the only option. Today multiple options are available for treatment.

Once the patient is diagnosed with trigeminal neuralgia, the usual course is to begin with medical therapy. The most effective drug for trigeminal neuralgia presently is Tegretol, although patients may variously respond to Neurontin, Lyrica, or similar medications. Although control may be initially very satisfactory, it is not uncommon for patients to begin to experience breakthrough on the medications. It is also not uncommon for patients to experience significant side effects from the medications that are utilized for the pain. This is particularly true in patients older than 65, a common time for onset of the painful disorder, although it can be seen in patients as young as in their late 20s to early 30s.

Once the medical therapy fails, there are fortunately other options available for management.  The most effective long-term treatment for trigeminal neuralgia is a surgical procedure known as microvascular decompression of the trigeminal nerve. The trigeminal nerve is a nerve which exits from the brainstem and courses into the face and supplies sensory information such as temperature and light touch back to the brain. The pain of trigeminal neuralgia is commonly precipitated by compression of the nerve near the brainstem by nearby blood vessels. The surgery is performed by opening the skull in the back of the head and dissecting under the operating microscope to the nerve where the blood vessel is found and dissected free from the nerve.  A small pad of Teflon coated cotton is then placed between the blood vessel and the nerve to give long-term alleviation of the pain. The procedure is 90% effective in relieving pain and gives excellent long-term benefit in patients who are candidates for the surgery. The surgery is generally reserved for patients who are in good health and 65 years of age or younger.

For patients not considered candidates for microvascular decompression, a very effective alternative treatment is available in the form of stereotactic radiosurgery. In Colorado Springs we have the availability of Cyberknife, which delivers a focused concentration of radiation to a site in the trigeminal nerve near the brainstem without incisions or pain. It is about 80% successful over a three to five year time frame in relieving the pain and has very low risk associated with it.  There is some recurrence of the pain over a five-year period but occasionally repeating the treatment may be an option.

Other options for treatment include procedures in which needles are inserted by the side of the mouth and directed toward the base of the skull for injection of glycerol or balloon compression or even heat treatments from a radiofrequency current. All of these procedures are designed to destroy fibers in the nerve to block the pain and may be associated with temporary or even permanent numbness in the face. They can also lead to a form of pain in the numb area which can pose significant treatment problems. These procedures are generally reserved for patients who have failed stereotactic radiosurgery and who are not felt to be suitable candidates for the other procedures.

The symptoms of trigeminal neuralgia are very specific and are classically defined so the selection for intervention is based on the judgment of a physician who is expert in the management of this condition. If you think you are affected by this condition or know someone who you think is affected by the condition, it is best to seek medical attention, as significant benefit may be afforded through different measures of intervention.