|Classification and external resources|
Trigeminal neuralgia (TN, or TGN), also known as prosopalgia, tic doloureux, or Fothergill's disease is a neuropathic disorder characterized by episodes of intense pain in the face. It has been described as among the most painful conditions known. The pain originates from a variety of different locations on the face and may be felt in front of the ear, eye, lips, nose, scalp, forehead, cheeks, mouth, or jaw and side of the face.
The pain of TN is from the trigeminal nerve. The trigeminal nerve is a paired cranial nerve that has three major branches: the ophthalmic nerve (V1), the maxillary nerve (V2), and the mandibular nerve (V3). One, two, or all three branches of the nerve may be affected. 1–6% of cases occur on both sides of the face but extremely rare for both to be affected at the same time. Trigeminal neuralgia most commonly involves the middle branch (the maxillary nerve or V2) and lower branch (mandibular nerve or V3) of the trigeminal nerve.
It is estimated that 1 in 15,000 or 20,000 people have TN, although the actual figure may be significantly higher due to misdiagnosis. In most cases, TN symptoms begin appearing over the age of 50, although there have been cases with people being as young as three years of age. It is more common in females than males. Trigeminal neuralgia was first described by physician John Fothergill and treated surgically by John Murray Carnochan, both of whom were graduates of the University of Edinburgh Medical School.
Signs and symptoms
This disorder is characterized by episodes of intense facial pain. Each individual attack of pain lasts from a few seconds to several minutes or hours, but these can repeat for hours with very short intervals between each attack. In other instances only 4-10 attacks are experienced daily. The episodes of intense pain may occur paroxysmally. To describe the pain sensation, patients often describe a trigger area on the face so sensitive that touching or even air currents can trigger an episode; however, in many patients the pain is generated spontaneously without any apparent stimulation. It affects lifestyle as it can be triggered by common activities such as eating, talking, shaving and brushing teeth. Wind, chewing and talking can aggravate the condition in many patients. The attacks are said by those affected to feel like stabbing electric shocks, burning, exploding, sharp, pressing, crushing, exploding or shooting pain that becomes intractable.
The pain also tends to occur in cycles with remissions lasting months or even years. 1-6% of cases occur on both sides of the face. This normally indicates problems with both trigeminal nerves, since one serves strictly the left side of the face and the other serves the right side. Pain attacks are known to worsen in frequency or severity over time, in some patients. Pain may migrate to other branches over time but in some patients remains very stable.
Rapid spreading of the pain, bilateral involvement or simultaneous participation with other major nerve trunks (such as Tic Convulsive of nerves V & VII or occurrence of symptoms in the V and IX nerves) may suggest a systemic cause. Systemic causes could include multiple sclerosis or expanding cranial tumours.
The severity of the pain makes it difficult to wash the face, shave, and perform good oral hygiene. The pain has a significant impact on activities of daily living especially as patients live in fear of when they are going to get their next attack of pain and how severe it will be. IIt can lead to severe depression and anxiety.
However, not all patients will have the symptoms described above and there are variants of TN. One of which is atypical trigeminal neuralgia ("trigeminal neuralgia, type 2" or trigeminal neuralgia with concomitant pain ), based on a recent classification of facial pain. In these instances there is also a more prolonged lower severity background pain that can be present for over 50% of the time and is described more as a burning or prickling, rather than a shock.
Trigeminal neuropathic pain is similar to TN2 but can have the electric pulses associated with classic TN. The pain is usually constant and can also give off a tingling, numbness sensation. This pain is due to unintentional damage to one or more of the trigeminal nerves from trauma, oral surgery, dentistry work, etc. It is difficult to treat but sufferers are usually given the same anticonvulsant and tricyclics antidepressant medicines as with the other types of neuralgias. Surgical options are DREZ (dorsal root entry zone) lesion and MCS or Motor Cortex Stimulation.
TN needs to be distinguished from other forms of unilateral pain which is related to damage to the trigeminal nerve by trauma to the face or dental treatments. This is often termed painful trigeminal neuropathy or post traumatic neuropathy as some sensory changes can be noted e.g decrease in pain sensation or temperature. This is important as different carepathways are used. Trigeminal pain can also occur after an attack of herpes zoster and post herpetic neuralgia has the same manifestations as in other parts of the body. Trigeminal deafferentation pain (TDP) also termed anaesthesia dolorosa is from intentional damage to a trigeminal nerve following attempts to surgically fix a nerve problem. this pain is usually constant with a burning sensation and numbness. TDP is very difficult to treat as further surgeries are usually ineffective and possibly detrimental to the patient.
The trigeminal nerve is a mixed cranial nerve responsible for sensory data such as tactition (pressure), thermoception (temperature), and nociception (pain) originating from the face above the jawline; it is also responsible for the motor function of the muscles of mastication, the muscles involved in chewing but not facial expression.
Several theories exist to explain the possible causes of this pain syndrome. It was once believed that the nerve was compressed in the opening from the inside to the outside of the skull; but newer leading research indicates that it is an enlarged blood vessel – possibly the superior cerebellar artery – compressing or throbbing against the microvasculature of the trigeminal nerve near its connection with the pons. Such a compression can injure the nerve's protective myelin sheath and cause erratic and hyperactive functioning of the nerve. This can lead to pain attacks at the slightest stimulation of any area served by the nerve as well as hinder the nerve's ability to shut off the pain signals after the stimulation ends. This type of injury may rarely be caused by an aneurysm (an outpouching of a blood vessel); by an AVM (arteriovenous malformation); by a tumor; by an arachnoid cyst in the cerebellopontine angle; or by a traumatic event such as a car accident.
Short-term peripheral compression is often painless, with pain attacks lasting no more than a few seconds. Persistent compression results in local demyelination with no loss of axon potential continuity. Chronic nerve entrapment results in demyelination primarily, with progressive axonal degeneration subsequently. It is, "therefore widely accepted that trigeminal neuralgia is associated with demyelination of axons in the Gasserian ganglion, the dorsal root, or both." It has been suggested that this compression may be related to an aberrant branch of the superior cerebellar artery that lies on the trigeminal nerve. Further causes, besides an aneurysm, multiple sclerosis or cerebellopontine angle tumor, include: a posterior fossa tumor, any other expanding lesion or even brainstem diseases from strokes.
Trigeminal Neuralgia is found in 3–4% of people with Multiple Sclerosis, according to data from seven studies. Only two to four percent of patients with TN, usually younger, have evidence of multiple sclerosis, which may damage either the trigeminal nerve or other related parts of the brain. It has been theorized that this is due to damage to the spinal trigeminal complex. Trigeminal pain has a similar presentation in patients with and without MS.
When there is no [apparent] structural cause, the syndrome is called idiopathic.
As with many conditions without clear physical or laboratory diagnosis, TN is sometimes misdiagnosed. A TN sufferer will sometimes seek the help of numerous clinicians before a firm diagnosis is made.
There is evidence that points towards the need to quickly treat and diagnose TN. It is thought that the longer a patient suffers from TN, the harder it may be to reverse the neural pathways associated with the pain.
The differential diagnosis includes temporomandibular disorder. Since triggering may be caused by movements of the tongue or facial muscles, TN must be differentiated from masticatory pain that has the clinical characteristics of deep somatic rather than neuropathic pain. Masticatory pain will not be arrested by a conventional mandibular local anesthetic block.
Dentists who suspect TN should proceed in the most conservative manner possible and should ensure that all tooth structures are "truly" compromised before performing extractions or other procedures.[medical citation needed]
- The anticonvulsant carbamazepine is the first line treatment; second line medications include baclofen, lamotrigine, oxcarbazepine, phenytoin, gabapentin, pregabalin, and sodium valproate. Uncontrolled trials have suggested that clonazepam and lidocaine may be effective.
- Duloxetine can also be used in some cases of neuropathic pain, and as it is also an antidepressant can be particularly helpful where neuropathic pain and depression are combined.
- Opiates such as morphine and oxycodone can be prescribed, and there is evidence of their effectiveness on neuropathic pain, especially if combined with gabapentin.
The evidence for surgical therapy is inconclusive and surgery is normally recommended only after medical treatment has proved ineffective. While there may be pain relief there is also frequently numbness post procedure. Microvascular decompression appears to result in the longest pain relief. Percutaneous radiofrequency thermorhizotomy may also be effective as may gamma knife radiosurgery, however the effectiveness decreases with time.
Three other procedures use needles or catheters that enter through the face into the opening where the nerve first splits into its three divisions. Some excellent success rates using a cost-effective percutaneous surgical procedure known as balloon compression have been reported. This technique has been helpful in treating the elderly for whom surgery may not be an option due to coexisting health conditions. Balloon compression is also the best choice for patients who have ophthalmic nerve pain or have experienced recurrent pain after microvascular decompression.
Glycerol injections involve injecting an alcohol-like substance into the cavern that bathes the nerve near its junction. This liquid is corrosive to the nerve fibers and can mildly injure the nerve enough to hinder the errant pain signals. In a radiofrequency rhizotomy, the surgeon uses an electrode to heat the selected division or divisions of the nerve. Done well, this procedure can target the exact regions of the errant pain triggers and disable them with minimal numbness.
Psychological and social support has found to play a key role in the management of chronic illnesses and chronic pain conditions, such as Trigeminal Neuralgia. Chronic pain can cause constant frustration to an individual as well as to those around them. As a result, there exists a wealth of support groups for Trigeminal Neuralgia, sufferers and carers, the largest of which is the Trigeminal Neuralgia Association (TNA) which exists in several different countries, including the UK (TNA UK), Australia and America (TNA - Facial Pain Association)
History, society and culture
- Entrepreneur and author Melissa Seymour was diagnosed with TN in 2009 and underwent microvascular decompression surgery in a well documented case covered by magazines and newspapers which helped to raise public awareness of the illness in Australia. Seymour was subsequently made a Patron of the Trigeminal Neuralgia Association of Australia.
- One of India's biggest film stars, Salman Khan, was diagnosed with TN in 2011, resulting in tremendous media coverage in the country and abroad. He underwent surgery in the US.
- All-Ireland winning Gaelic footballer Christy Toye was diagnosed with the condition in 2013. He spent five months in his bedroom at home, returned for the 2014 season and lined out in another All-Ireland final with his team.
- Gallium maltolate in a cream or ointment base has been studied in a case report as a treatment of refractory postherpetic trigeminal neuralgia.
- Hackley, CE (1869). A text-book of practical medicine. D. Appleton & Co. p. 292. Retrieved 2011-08-01.
- Bagheri, SC; et al. (December 1, 2004). "Diagnosis and treatment of patients with trigeminal neuralgia". Journal of the American Dental Association 135 (12): 1713–7. doi:10.14219/jada.archive.2004.0124. PMID 15646605. Retrieved 2011-08-01.
- Okeson, JP (2005). "6". In Lindsay Harmon. Bell's orofacial pains: the clinical management of orofacial pain. Quintessence Publishing Co, Inc. p. 114. ISBN 0-86715-439-X.
- http://www.ncbi.nlm.nih.gov/pmc/ articles/PMC4258705
- Trigeminal neuralgia and hemifacial spasm by UF&Shands – The University of Florida Health System. Retrieved Mars 2012
- Satta Sarmah (2008). "Nerve disorder's pain so bad it's called the 'suicide disease'". Medill Reports Chicago. http://news.medill.northwestern.edu/chicago/news.aspx?id=79817
- Bloom, R. "Emily Garland: A young girl's painful problem took more than a year to diagnose".
- Bayer DB, Stenger TG (1979). "Trigeminal neuralgia: an overview". Oral Surg Oral Med Oral Pathol 48 (5): 393–9. doi:10.1016/0030-4220(79)90064-1. PMID 226915.
- Okeson, JP (2005). "17". In Lindsay Harmon. Bell's orofacial pains: the clinical management of orofacial pain. Quintessence Publishing Co, Inc. p. 453. ISBN 0-86715-439-X.
- "Neurological surgery: facial pain". Oregon Health & Science University. Retrieved 2011-08-01.
- Burchiel KJ (2003). "A new classification for facial pain". Neurosurgery 53 (5): 1164–7. doi:10.1227/01.NEU.0000088806.11659.D8. PMID 14580284.
- Singh N, Bharatha A, O’Kelly C, Wallace MC, Goldstein W, Willinsky RA, Aviv RI, Symons SP. Intrinsic arteriovenous malformation of the trigeminal nerve. Canadian Journal of Neurological Sciences. 2010 September; 37(5):681–683.
- Babu R, Murali R (1991). "Arachnoid cyst of the cerebellopontine angle manifesting as contralateral trigeminal neuralgia: case report". Neurosurgery 28 (6): 886–7. doi:10.1097/00006123-199106000-00018. PMID 2067614.
- Croft, Stephen M. Foreman, Arthur C. (2002). Whiplash injuries : the cervical acceleration/deceleration syndrome (3rd ed.). Baltimore: Williams & Wilkins. p. 481. ISBN 9780781726818.
- Okeson, JP (2005). "6". In Lindsay Harmon. Bell's orofacial pains: the clinical management of orofacial pain. Quintessence Publishing Co, Inc. p. 115. ISBN 0-86715-439-X.
- Foley P, Vesterinen H, Laird B, et al. (2013). "Prevalence and natural history of pain in adults with multiple sclerosis: Systematic review and meta-analysis". Pain 154 (5): 632–42. doi:10.1016/j.pain.2012.12.002. PMID 23318126.
- Cruccu G, Biasiotta A, Di Rezze S, et al. (2009). "Trigeminal neuralgia and pain related to multiple sclerosis". Pain 143 (3): 186–91. doi:10.1016/j.pain.2008.12.026. PMID 19171430.
- De Simone R, Marano E, Brescia MV, et al. (2005). "A clinical comparison of trigeminal neuralgic pain in patients with and without underlying multiple sclerosis". Neurol Sci. 26 Suppl 2: s150–1. doi:10.1007/s10072-005-0431-8. PMID 15926016.
- Drangsholt, M; Truelove, EL (2001). "Trigeminal neuralgia mistaken as temporomandibular disorder". J Evid Base Dent Pract 1 (1): 41–50. doi:10.1067/med.2001.116846.
- Sindrup, SH; Jensen, TS (2002). "Pharmacotherapy of trigeminal neuralgia". Clin J Pain 18 (1): 22–7. doi:10.1097/00002508-200201000-00004. PMID 11803299.
- Lunn, MPT; Hughes, R.A.C; Wiffen, P.J (7 October 2009). "Duloxetine for treating painful neuropathy or chronic pain". In Lunn, MPT. Duloxetine for treating painful neuropathy or chronic pain. The Cochrane Database of Systematic Reviews. doi:10.1002/14651858.CD007115.pub2. Retrieved 2011-08-01.
- "news item – Morphine plus gabapentin better combined than separate in neuropathic pain". Ukmicentral.nhs.uk. 2005-03-31. Retrieved 2013-10-09.
- Zakrzewska, JM; Akram, H (Sep 7, 2011). "Neurosurgical interventions for the treatment of classical trigeminal neuralgia.". Cochrane database of systematic reviews (Online) 9: CD007312. doi:10.1002/14651858.CD007312.pub2. PMID 21901707.
- Sindou, M; Keravel, Y (April 2009). "[Algorithms for neurosurgical treatment of trigeminal neuralgia].". Neuro-Chirurgie 55 (2): 223–5. doi:10.1016/j.neuchi.2009.02.007. PMID 19328505.
- Sindou, M; Tatli, M (April 2009). "[Treatment of trigeminal neuralgia with thermorhizotomy].". Neuro-Chirurgie 55 (2): 203–10. doi:10.1016/j.neuchi.2009.01.015. PMID 19303114.
- Dhople, AA; Adams, JR; Maggio, WW; Naqvi, SA; Regine, WF; Kwok, Y (August 2009). "Long-term outcomes of Gamma Knife radiosurgery for classic trigeminal neuralgia: implications of treatment and critical review of the literature. Clinical article.". Journal of neurosurgery 111 (2): 351–8. doi:10.3171/2009.2.JNS08977. PMID 19326987.
- Natarajan, M (2000). "Percutaneous trigeminal ganglion balloon compression: experience in 40 patients". Neurology (Neurological Society of India) 48 (4): 330–2. PMID 11146595.
- Molitor, Nancy. "Dr". American Psychological Association. APA. Retrieved 27 June 2015.
- Williams, Christopher; Dellon, A.; Rosson, Gedge (5 March 2009). "Management of Chronic Facial Pain". Craniomaxillofacial Trauma and Reconstruction 2 (02): 067–076. doi:10.1055/s-0029-1202593. PMC 3052669. PMID 22110799.
- "Facial Neuralgia Resources". Trigeminal Neuralgia Resources / Facial Neuralgia Resources. Retrieved 8 May 2013.
- Adams, H; Pendleton, C; Latimer, K; Cohen-Gadol, AA; Carson, BS; Quinones-Hinojosa, A (May 2011). "Harvey Cushing's case series of trigeminal neuralgia at the Johns Hopkins Hospital: a surgeon's quest to advance the treatment of the 'suicide disease'.". Acta neurochirurgica 153 (5): 1043–50. doi:10.1007/s00701-011-0975-8. PMID 21409517.
- Prasad, S; Galetta, S (2009). "Trigeminal Neuralgia Historical Notes and Current Concept". Neurologist 15 (2): 87–94. doi:10.1097/NRL.0b013e3181775ac3. PMID 19276786. Retrieved 2011-08-01.
- "Melissa Seymour: My perfect life is over". Womansday.ninemsn.com.au. 2009-06-18. Retrieved 2013-10-09.
- "Salman suffering from the suicide disease". http://www.hindustantimes.com. 2011-08-24. Retrieved 2014-06-18.
- Foley, Alan (16 September 2014). "Serious illness meant Christy Toye didn't play in 2013 but now he's set for All-Ireland final: The Donegal player has experienced a remarkable revival". The Score. Retrieved 16 September 2014.
- Bernstein, L.R. (2013). "Gallium, therapeutic effects" (PDF). In Kretsinger, R.H.; Uversky, V.N.; Permyakov, E.A. Encyclopedia of Metalloproteins. New York: Springer. pp. 823–835. ISBN 978-1-4614-1532-9.