Trigeminal neuralgia

The significant symptoms of trigeminal neuralgia include:

• A sudden attack of severe, sharp, shooting pain that lasts for a few seconds to a few minutes.
• The pain is often described as electric shock-like, burning, pressing, crushing, exploding, shooting, migraine-like, piercing, prickling, or a combination of these sensations.
• The pain is usually felt in the teeth, lower jaw, upper jaw, or cheek, with the right side of the face more often affected than the left.
• Typically, the pain resolves completely between attacks, known as a refractory period.
• Attacks are generally stereotyped or follow the same pattern in an individual patient.
• In severe cases of trigeminal neuralgia, attacks may occur hundreds of times a day, and there may be no periods of remission.

Trigeminal neuralgia is also referred to as tic douloureux because extreme pain can cause patients to make facial expressions and move their heads away from the pain; this movement is known as a tic.

The activities that can trigger the symptoms of trigeminal neuralgia include:

• Light touch
• Washing the face
• Shaving
• Head movements
• Swallowing
• Chewing
• Smiling
• Talking
• A cool breeze against the face
• Traveling in a car

Trigeminal neuralgia is caused by compression of the trigeminal nerve, which is the largest nerve inside the skull. This nerve conducts the sensation of pain and touch from the teeth, face, and mouth to the brain.

Primary Trigeminal Neuralgia

Primary trigeminal neuralgia is caused by the compression of the trigeminal nerve at the base of the head where it enters the brain stem (the lowest part of the brain). In most cases, the pressure is caused by an artery or vein compressing the trigeminal nerve.

In some cases, the pressure on the nerve wears away its protective outer layer (myelin sheath), which may cause pain signals to travel along the nerve.

Secondary Trigeminal Neuralgia

Secondary trigeminal neuralgia occurs when neuralgia is caused by another medical condition or disease. Examples include:

• Cysts
• Tumor
• Facial injury
• Damage caused by surgery
• Viral infections like shingles, chickenpox, and herpes

Most often, the cause of trigeminal neuralgia is idiopathic, meaning the exact cause is not known. However, the following risk factors can increase the chances of developing trigeminal neuralgia:

Age

The risk of trigeminal neuralgia increases with age, particularly in individuals between the ages of 50 and 60 years. This is attributed to the hardening of blood vessels and sagging of the brain, which can lead to the formation of new contacts between nerves and blood vessels.

Sex

Women are more likely to develop trigeminal neuralgia than men.

Systemic Conditions

• Multiple sclerosis: A significant risk factor for trigeminal neuralgia, this autoimmune disease affects the protective myelin sheath of the body's nerves, predisposing individuals to the condition.
• Diabetes: Diabetes can increase the risk of developing trigeminal neuralgia, possibly due to nerve damage caused by hyperglycemia (high blood glucose).
• Sarcoidosis: This disease is characterized by the growth of small collections of inflammatory cells (granulomas) in various parts of the body and has been occasionally associated with trigeminal neuralgia.
• Lyme disease: An infection resulting from a tick bite, Lyme disease can rarely increase the risk of trigeminal neuralgia due to its systemic inflammatory nature.
• Scleroderma: Also known as systemic sclerosis, this group of rare diseases involves the hardening and tightening of the skin. Some individuals with scleroderma have a higher likelihood of developing trigeminal neuralgia.
• Systemic lupus erythematosus (SLE): An autoimmune disease where the immune system attacks its own tissues, causing widespread inflammation. In rare cases, SLE can lead to the immune system attacking the trigeminal nerve, resulting in trigeminal neuralgia.

The doctor may consider the following methods to diagnose trigeminal neuralgia (TN):

• Medical history and physical examination: A complete physical examination and a detailed medical history are required to rule out other causes of facial pain. The medical practitioner will ask about:
• Intensity of pain attacks
• Duration of pain attacks
• Affected areas of the face

There is no specific test for TN; therefore, its diagnosis is usually based on the individual’s symptoms and description of the pain.

An important aspect of diagnosing trigeminal neuralgia involves ruling out other conditions that lead to facial pain, such as:

• Joint pain in the lower jaw
• Toothache
• Nerve injury
• Migraine (a headache that can cause severe throbbing pain or a pulsing sensation, usually on one side of the head)

Imaging Techniques:

• Magnetic Resonance Imaging (MRI): This test helps in diagnosing the possible cause of facial pain, such as inflammation of the lining of the sinuses, nerve damage caused by multiple sclerosis, and tumors on facial nerves. An MRI scan can also detect whether a blood vessel is compressing one of the trigeminal nerves.
• Computed Tomography (CT) scan (head): Computed tomography (CT) of the head uses special x-ray equipment to help assess and identify tumors or multiple sclerosis, which can cause secondary trigeminal neuralgia.

Trigeminal neuralgia is not preventable. However, certain triggering factors can be avoided by taking necessary precautions:

• Wind: If wind is a trigger, wearing a scarf around the face can provide protection.
• Cold drinks: Using a straw to drink cold water or beverages can prevent the liquid from coming into direct contact with painful areas.
• Chewing: Liquidizing meals may help if chewing food is difficult.
• Avoid certain foods: Some foods may trigger attacks; it is advisable to avoid items such as citrus fruits, bananas, and caffeine.

Correct diagnosis and proper management also benefit patients and lead to a favorable prognosis.

Management of TN depends on multiple factors, including age, general health, disease severity, and other medical conditions. Medicines can be used to control the pain, or surgery may be considered where drugs have been ineffective for the long term.

Medications

The first-line treatment for patients with TN is pharmacologic therapy. Painkillers like paracetamol are not effective; therefore, an anticonvulsant is prescribed for the treatment.

• The most commonly used anticonvulsant drug is carbamazepine. This medicine is usually started at a lower dose and gradually increased to control the pain. The pain is controlled for most people in the early stages of the disease. However, in some patients, the effectiveness of carbamazepine decreases over time.
• Another anticonvulsant drug, gabapentin, which is most commonly used to treat epilepsy or migraines, can also treat TN.
• Other medicines used to treat trigeminal neuralgia include oxcarbazepine, baclofen, and pregabalin.

Percutaneous procedure

Percutaneous procedures are performed through the smallest possible working incision, by inserting a needle or thin tube through the cheek and into the trigeminal nerve inside the skull. X-rays of the head and neck are usually performed to help guide the needle into the correct place.

The various percutaneous procedures to treat trigeminal neuralgia are:

• Radiofrequency lesioning (Rhizotomy): Rhizotomy provides pain relief to approximately 80% of patients with TN, but it’s a temporary solution that usually lasts 1-3 years until the nerve regrows. The surgeon inserts a long needle through the cheek on the affected side of the face and uses heat or a chemical to suppress the pain fibers of the trigeminal nerve.
• Glycerol injections: This involves the injection of a small amount of glycerol into the trigeminal nerve to block pain signals to the brain. This method is mostly used in patients who are immunocompromised by other chronic diseases.
• Balloon compression: The surgeon will insert a tube, called a cannula, through your cheek up to the trigeminal nerve. A thin, flexible tube with a balloon on one end is then weaved through the needle. This procedure has been known to relieve symptoms for 1-2 years, though it can cause some numbness in the face.

Surgery

• Microvascular decompression (MVD): This is one of the most common surgical procedures used to treat trigeminal neuralgia. It can help relieve pain without intentionally damaging the trigeminal nerve. This surgery reveals the blood vessel that may be compressing the nerve and provides the longest relief from trigeminal neuralgia.
• Stereotactic radiosurgery: This procedure delivers a highly concentrated and precise beam of radiation on the trigeminal nerve root to relieve the pain. It’s always recommended that patients receive it no more than two times as a treatment for trigeminal neuralgia.

There are no highly effective home remedies for trigeminal neuralgia. However, you can try the following after consent from your doctor. They will act as an adjunct to conventional medical treatment:

• Hot or Cold Compression: Taking a hot shower or bath can help relieve the symptoms. Cold compressions, like ice or cold water, can also help relieve painful episodes.
• Peppermint: It is used as a pain reliever and helps in relaxing the muscles to control muscle spasms. Peppermint oil can be used alone or combined with a carrier oil to minimize pain and irritation caused by trigeminal neuralgia. Peppermint oil has some amazing benefits to offer to your body.
• Basil (Tulsi): This effective herb has been used for over 3000 years due to its incredible healing powers. It acts as a stress regulator and inhibits nerve pain in cases of trigeminal neuralgia. Essential oil of basil can be applied to the affected area for instant relief.
• Dietary Supplements: The addition of vitamins B12 and minerals in the diet can help alleviate the discomforting symptoms of trigeminal neuralgia. Most individuals are deficient in Vitamin B12. Fill in the gaps in your diet with our extensive range of supplements.

The pain in Trigeminal Neuralgia can be so severe and exhausting that patients may develop anxiety and depression if not properly treated.

Patients treated with anticonvulsant drugs for the long term may experience unfavorable drug effects.

Some patients may permanently develop facial numbness on the affected side.

The surgical procedures for treatment can pose some intraoperative and postoperative risks.

Acupuncture: Acupuncture involves the insertion of thin needles along the trigger points to provide pain relief. Precautions must be taken while inserting the acupuncture needles to avoid contact with trigger areas, as this may exacerbate the symptoms.

Meditation: Meditation therapy can help alleviate the pain caused by trigeminal neuralgia. This technique promotes slow breathing and relaxation, which can ease or prevent stimulation of the trigeminal nerve. Meditation is beneficial for both the soul and body.

Aromatherapy: Essential oils, such as chamomile and lavender, can help ease neuropathic discomfort. While this therapy may not work for everyone, it can provide relief from the pain of trigeminal neuralgia for some individuals.

Although Trigeminal Neuralgia is not fatal, it causes pain and anxiety, which can ultimately affect the patient's quality of life. A person may find themselves feeling overwhelmed and isolated at times. Caring for mental health, connecting with others, and practicing self-care can all go a long way in preserving the quality of life. Here are a few steps to follow while living with this condition:

• Look after mental health: The chronic repetitive and unpredictable shots of stabbing pain can leave people isolated and vulnerable to depression and anxiety. In some extreme cases, even suicidal thoughts can emerge. Participating in social interactions and engaging in small household tasks can help divert the mind.
• Avoid triggers: While TN pain attacks are often spontaneous, some people with TN identify specific triggers that bring on their pain attacks. Common triggers include spicy foods, cold beverages, and chewing. If a person identifies their triggers, a conscious effort to avoid them may help alleviate TN pain.
• Practice a healthy lifestyle and general self-care: Looking after your overall health through a balanced diet, regular exercise, a consistent sleep schedule, and mental healthcare is crucial. Managing TN is much easier when the rest of the body is cared for by leading a healthy life.

If your loved one has Trigeminal Neuralgia, the following pointers can help you extend a helping hand to the patient:

• Understanding the severity of the pain the person is experiencing and being accommodating are the first steps to caring for a loved one with Trigeminal Neuralgia.
• Helping your loved one stay on track with their medications and communicating about the success of the treatment.
• Encouraging doctor visits and exploring other treatment options when medications stop working.