FACIAL PAIN:
TRIGEMINAL NEURALGIA
This type of pain usually is limited one part of the face on either the right or left side, and always recurs in the same distribution of the trigeminal nerve. The pain is sudden, severe, brief, electric, stabbing or lancinating. Pain recurs in bout or paroxysms, often with a dull sensation between the shock-like flashes, which were was called tic douloureux in the past. Each shock of pain lasts one to several seconds. The pain usually affects the cheek or jaw, less frequently at eye, brow or throat, but always in the area supplied with sensory fibers of one of the three trigeminal branches (ophthalmic, maxillary or mandibular). Light touch of the skin or in the mouth can trigger severe spasms of pain in the so-called “trigger zones”. Talking, chewing, brushing the teeth, smiling, cold air or a blustery wind can trigger pain. The patient may experience the pain as the result of a dental problem and will see the dentist who may or may not find dental problems. There still remains confusion as to the significance of dental procedures being the cause of or merely incidental to the pain. Episodes of pain may continue for weeks or months before spontaneously improving, than recurring months to years later, often in a cyclical manner. Some bouts may be less severe, others excruciating. The condition is not familial or based on a known genetic pattern.
The diagnosis of trigeminal neuralgia is based upon the history of the patient and the findings on neurological (and dental) examination. It is important initially to exclude problems of the eye, the teeth, the jaw, the sinuses, or other areas of the head. Before making an appointment with the neurologist, the patient will usually already have seen a dentist or ophthalmologist.
Imaging of the brain with an MRI is often done on the onset of the condition but rarely will need to be repeated on later recurrences. Very few imaging studies reveal abnormalities that can explain the facial pain; these can include multiple sclerosis, aneurysms or small tumors close to the trigeminal nerve. Pain also has been claimed as the result of compression of the nerve by an artery, often described as a “vascular loop” seen on the images. Younger patients under age 40 years, those with pain and weakness, or pain with loss of sensation are more likely to need immediate brain imaging.
Doctors make a distinction between the more common type of “idiopathic” neuralgia (meaning basically that there is no apparent cause of the pain) and the rare “secondary” or “symptomatic” neuralgia, which is due to an underlying structural abnormality in the brain.
Other causes of facial pain will be considered by Dr. Rosenkilde before a diagnosis is made. Shingles from herpes zoster can cause severe pain in the absence of a rash, or after its resolution. A pinched nerve in the upper neck can produce referred pain in the scalp, the ear or the cheek. Temporal or giant cell arteritis is an inflammation of arteries with headaches, upper facial or jaw pain, sometimes with blurry vision. Pain can persist after trauma or surgery to head, sinuses, neck, teeth, or jaw. The pain of migraine consistently may be localized to areas of the face, so that the patient will deny a headache condition, looking for another diagnosis. Sinus and dental conditions should always be excluded before diagnosis is made of trigeminal neuralgia. The “Jabs and jolts syndrome” can be a manifestation of migraines. Temporomandibular joint conditions can present as facial pain or headaches.
TREATMENT
Medications for trigeminal neuralgia are unlike those used for other pains and aches. Many of the drugs for epilepsy have been useful, including carbamazepine, oxcarbazepine, gabapentine, lamotrigine, valproate, pregabalin, and phenytoin. Baclofen and clonazepam have also been used. Narcotics and anti-inflammatory medications have been of limited use. When pain has been intractable, a second drug may be added to the first line medication. If feasible, any underlying cause should be treated separately.
If medications do not work, and the pain is persisting and unbearable, a variety of more aggressive treatments have been tried over the years. Surgery is now rarely ever needed. The most successful procedure with least invasiveness is Gamma Knife Radiosurgery, essentially focused radiation to a site inside the brain where the pain originates. The radiation beam causes nerve damage in a tiny area, and the pain improves after a delay of 1 to 6 months. Facial numbness or tingling occurs as a complication in some patients.
Perhaps Picasso was thinking about trigeminal neuralgia when he painted this portrait.
"No, doctor, the pain intensity is not an your scale from 1 to 10. It is a 20, and it feels like it is July 4 fireworks in my face."
Quote by a patient with trigeminal neuralgia.
