Trigeminal neuralgia is an extremely painful condition which causes jolts of very intense electric-like pains in the face. Fortunately, many trigeminal neuralgia sufferers respond to medications or Botox injections.

Several surgical procedures have also been used to treat this condition. One of these procedures is destruction of the trigeminal ganglion. The most effective treatment involves opening the skull and placing a teflon pad between the trigeminal nerve and the blood vessel which compresses the nerve (this procedure is called microvascular decompression). This pressure on the trigeminal nerve by an artery is the cause of pain in the majority of patients. While surgery can be truly curative, it carries a risk of serious complications and should be done only if medications and Botox injections fail. Ideally, it should be performed by a surgeon who has performed hundreds of these operations.

Besides medications, Botox, and injections to destroy the trigeminal ganglion, stereotactic radiosurgery, or gamma knife, offers another alternative to brain surgery. This treatment appears to be very effective and a new study published in Neurology suggests that this procedure is more effective if it is done early. If gamma knife radiosurgery is done within a year of the onset of pain, patients remained pain free for an average of 68 months, while if it was done more than 3 years after the onset, the relief lasted only 10 months.

Although microvascular decompression is curative, two groups of patients may opt for radiosurgery. One group consists of patients who are poor surgical candidates because they have other medical conditions which may increase the risk of complications or death. Another group include those who are afraid to have open brain surgery and who prefer to have stereotactic radiosurgery.

As a side note I should mention that gamma knife, or stereotactic radiosurgery is the treatment of choice for most cases of acoustic neuroma, a benign tumor of the vestibular nerve, a nerve going from the inner ear to the brain. Open surgery almost always leads to facial paralysis and complete loss of hearing, while gamma knife can shrink the tumor without any damage to healthy tissues.

Trigeminal neuralgia is a very painful and debilitating condition (Here is a review article I wrote for physicians). Fortunately, it is relatively infrequent – affecting 0.3% of the population, compared to 12% afflicted by migraines. This explains relative paucity of studies of this condition. A group of neurologists at the Danish Headache Center studied 158 consecutive patients with trigeminal neuralgia (TN) seen at their center over a period of one year. They published their findings in the journal Headache.

Average age of onset of pain was 53 years. TN was more common in women than men (60% vs 40%) and more common on the right side (56%). When only one of the three branches of the trigeminal nerve were affected, the first and the second were involved in 69% of cases and the third branch (lower third of the face) alone was involved in only 7% of sufferers.

The pain of trigeminal neuralgia is described the same way by almost all sufferers – it feels like a strong electric shock. It can be triggered by chewing, brushing teeth, speaking, air movement from wind or air conditioner, and at times it occurs without any provoking factor. In this study, half of the patients reported having a more persistent but milder pain in addition to the typical stabbing, electric-like pain. One fifth of patients reported to have some tearing on the side of pain and in 17% there was some loss of sensation over the area of pain.

Treatment of TN usually begins with epilepsy drugs,such as carbamazepine (Tegretol) or oxcarbazepine (Trileptal). Although 89% of patient in this study reported some improvement, only 56% of them were taking these medications because in others they caused unacceptable side effects. Other drugs that can be helpful for TN include baclofen (a muscle relaxant) and Botox injections. I’ve treated a handful of patients with TN with Botox
and about half of them responded. Botox is injected into the area of pain, which tends to be small and only a very small amount of Botox needs to be injected. Injections of Botox are safer than any oral medication, but depending on the area injected, they can cause cosmetic side effects – asymmetric appearance of the face. Botox is approved by the FDA for chronic migraines but not TN, which means that insurance companies are not likely to pay for it. However, only about one tenth of the amount of Botox used for migraine is needed to treat TN, the cost is much lower.

The authors plan to provide additional information about this group of patients in future publications.

A new combination of two old drugs seems to provide relief for some trigeminal neuralgia (TN) sufferers. The first line drugs for TN are epilepsy drugs, carbamazepine (Tegretol) or oxcarbazepine (Trileptal). A presentation at the last annual scientific meeting of the American Headache Society by Saudi physicians described successful use of another epilepsy/pain drug, pregabaline (Lyrica) with an antidepressant/pain drug duloxetine (Cymbalta). Both Lyrica and Cymbalta are approved by the FDA for the treatment of some pain conditions, although not TN. The doctors compared Lyrica alone with Lyrica and Cymbalta in combination in 200 patients. The combination resulted in an 80% reduction of pain, which was observed within 10 days, while Lyrica alone produced a 60% reduction that started within 20 days. The dose of Lyrica was 150 mg twice a day (after a one week build up from 75 mg twice a day) and the dose of Cymbalta was 60 mg a day.

Since both Cymbalta and Lyrica have pain relieving properties, this appears to be a rational combination of medications to use in TN and possibly other painful conditions, including various types of headaches. However, as a general rule, we try to use a single drug whenever possible to reduce the potential for side effects. TN is such a severe and debilitating condition, that it may be justified to use a combination early, especially if the first line drugs, such as oxcarbazepine fail.

In my previous posts I have described the use of intravenous medications, Botox and other invasive treatments for TN.

Advances in MRI imaging have allowed visualizing the trigeminal nerve and a group of Australian researchers reported on their findings in three conditions which cause facial pain. Trigeminal nerve supplies sensation to the face and facial pain of any kind is also transmitted to the brain through this nerve. Their report, which appeared in The Journal of Pain, suggests that imaging trigeminal nerve may help in making a more accurate diagnosis, which is turn may lead to more appropriate treatment.

Trigeminal neuralgia is an extremely painful condition which is characterized by very brief electric-like pains in the face. The pain is triggered by chewing, talking, brushing teeth, touching a specific spot on the face, and at times occurring without any provocation. This condition usually results from compression of the trigeminal nerve by a blood vessel as it exits the brain stem. Treatment usually involves epilepsy drugs, such as carbamazepine (Tegretol) or oxcarbazepine (Trileptal), Botox injections, nerve destruction (radiofrequency thermocoagulation) or if nothing else works, surgery (microvascular decompression of the trigeminal nerve).

Trigeminal neuropathy also causes pain in the face, but it is less intense, usually continuous and is often burning in character. It can result from an injury to the trigeminal nerve in the periphery rather than near the brain stem. Dental procedures and facial injuries can trigger this pain. This pain tends to respond better to antidepressants, such as amitriptyline (Elavil), nortriptyline (Pamelor), protriptyline (Vivactil), and an epilepsy drug, gabapentin (Neurontin).

Temporomandibular joint disorders can result from arthritic changes in this joint, displacement of the cartilaginous disc inside the joint, or from muscle spasm and inflammation around the joint.

Using special MRI techniques the researchers discovered that patients with trigeminal neuralgia had thinning of the nerve, while those with trigeminal neuropathy had thicker trigeminal nerves than normal controls. Patients with temporomandibular disorders had normal thickness of their trigeminal nerves. This is a very useful finding, particularly when the diagnosis is not clear since some patients may have symptoms of both neuralgia and neuropathy. We often have to try several drugs before finding one that is effective and does not cause side effects, so it would be helpful to know from the start which drugs are more likely to work.

Art credit: JulieMauskop.com

Trigeminal neuralgia is an extremely painful condition that causes electric-like pain in the face. It is often misdiagnosed as a dental problem, sinus headache or another condition. The pain is very brief, just like an electric shock, but it can occur continuously and is often triggered by brushing teeth, chewing, talking, or even by wind. This is a very treatable condition and it usually responds to anti-epilepsy drugs, Botox injections and, if those fail, surgery. Many patients have periods of sudden worsening of pain and until medications or Botox begin to help they need emergency treatment for pain. Narcotics (opioids) are usually ineffective. Dr. Merritt and Cohen of the Beth Israel Hospital in New York recently described the use of intravenous antiepileptic medications for acute exacerbations of trigeminal neuralgia in the emergency department. They described 21 patients, 15 women and 6 men whose aged ranged from 33-88 and the mean age was 69 (trigeminal neuralgia is more common in the elderly). 19 received intravenous fosphenytoin (Cerebyx, a drug related to an oral drug Dilantin) 2 received levetiracetam (Keppra) with excellent relief. Side effects included double vision, dizziness, sleepiness, and itchiness with fosphenytoin and no side effects were observed in 2 who received levetiracetam. Unfortunately, the most commonly used oral drugs for trigeminal neuralgia, carbamazepine (Tegretol) and oxcarbazepine (Trileptal) are not available in an injectable form. Another epilepsy drug, divalproex sodium (Depakote) can be given intravenously (Depakene) but it does not appear to be very effective for trigeminal neuralgia.

Art credit: JulieMauskop

Botox injections relieve pain of trigeminal neuralgia, according to a new study just published in Cephalalgia, a leading headache journal. Trigeminal neuralgia is an extremely painful condition which manifests itself by intense electric shock-like pain on one side of the face. The pain is triggered by speaking, chewing and often without any provocation. Persistent pain can lead to malnutrition from the inability to chew and to severe depression and despondency. Epilepsy drugs, such as carbamazepine (Tegretol), oxcarbazepine (Trileptal), and other types of drugs often relieve the pain, but not always and at times the drugs can cause intolerable side effects.
Research on the mechanism of action of Botox has shown that it may be blocking sensory nerves and this led me to try Botox for a few of my patients with conditions other than chronic migraines and other headaches. Several patients with post-herpetic neuralgia (shingles) and a few with trigeminal neuralgia responded very well.
This rigorous double-blind, placebo-controlled study in Cephalalgia by Chinese researchers involved 42 patents with trigeminal neuralgia, of whom 40 completed the study. Among the patients who received Botox injections, 68% had significant improvement compared to only 15% of responders in the group tht received placebo. This study strongly suggests that Botox is an effective treatment for some patients with trigeminal neuralgia. The advantage of Botox is that it has significantly fewer side effects than oral drugs.