What is trigeminal neuralgia?
The facial pain of trigeminal neuralgia is one of the most severe pain at all. Many sufferers suffer considerably from the painful attacks on the face, which occur completely unpredictably and thus make a normal life almost impossible. Today, effective drugs or various surgical techniques are available for the treatment of trigeminal neuralgia. These treatments can often be used to achieve complete freedom of pain.
Trigeminal neuralgia is a painful disorder of the nerve of the same name (trigeminal nerve) and leads to sudden, flashy, violent attacks of pain in the face. Normally, the trigeminal nerve transmits sensations from the area of the facial to the brain. In a trigeminal neuralgia, the nerve reports strongest pain to the brain, although the skin is intact and no apparent damage is exposed.
The pain with trigeminal neuralgia usually last only for seconds (rarely longer than 2 minutes). There is usually a lack of freedom between the painful attacks. The symptoms of trigeminal neuralgia can occur in the entire supply area of the trigeminal nerve, that is, in the entire face and especially in the area of the cheeks, the lips, the tongue and the chewing musculature.
The disease is rare: in about four out of every 100,000 persons, a trigeminal neuralgia occurs every year for the first time. Women are somewhat more affected because of their higher life expectancy, as the probability of disease increases with age. The causes are still not fully understood, which makes the treatment of trigeminal neuralgia more difficult.
The International Headache Society (IHS) divides the trigeminal neuralgia into two groups, the symptomatic trigeminal neuralgia and the classical trigeminal neuralgia.
Trigeminal neuralgia symptoms
Characteristic of the pain in trigeminal neuralgia is mainly at the following:
- Suddenly, flash-like
- Extremely strong
- Short duration (split seconds to two minutes)
- The trigeminal neuralgia pain can often be repeated (up to a hundred times a day), but may also be interrupted by longer pain-free intervals. Often the pain is described as “lightning-like from the serenity of the sky”.
Typical triggers of a pain attack in a trigeminal neuralgia may be, for example, touching the skin in the face area, speaking, brushing the teeth or chewing or swallowing. The pain in a trigeminal neuralgia can also occur without any triggering stimulus.
Occasionally, in addition to the pain, there is also a reflexive twitching of facial muscles which is why trigeminal neuralgia is sometimes referred to as “tic douloureux”. The pain in trigeminal neuralgia is among the most severe pain at all. For fear of a pain attack, some patients even avoid the food intake, so that the weight loss and fluid deficiency may be severe. Due to the severe psychological stress caused by the pain in a trigeminal neuralgia, the patients also suffer from a depressive mood.
What are the causes and risk factors of trigeminal neuralgia?
If a clear cause of the pain attacks was demonstrated in radiological imaging or surgery, one speaks of symptomatic trigeminal neuralgia. If the cause of the pain is unclear, it is called classical trigeminal neuralgia. The division into these two groups has an impact on trigeminal neuralgia therapy.
Symptomatic trigeminal neuralgia: In addition to the pain, sensory disturbances (eg, tingling, numbness, etc.) can occur in the supply area of the trigeminal nerve. There must not necessarily be pain-freeness between the individual attacks. Patients with a symptomatic trigeminal neuralgia are on average younger than people with the classic disease form. In addition, bilateral facial pain occurs more frequently.
Trigeminal neuralgia therapy of the symptomatic form depends on the underlying cause. Often an operative intervention in symptomatic trigeminal neuralgia can alleviate the pain or completely eliminate it. Possible causes of symptomatic trigeminal neuralgia are:
- Degenerative diseases such as multiple sclerosis (MS)
- Brain tumors, especially acoustic neuromas. The tumor exerts a pressure on a blood vessel or on the trigeminal nerve, so that both are pressed against one another, resulting in pain.
Classical trigeminal neuralgia: No clear cause can be detected in classical trigeminal neuralgia. It is thought that the pain is caused by the direct contact between a blood vessel and the trigeminal nerve. Through this direct contact and pressure of the blood vessel on the trigeminal nerve, the covering of the nerve (myelin sheath) is damaged, which triggers the pain. The classical trigeminal neuralgia is treated predominantly conservatively with medicaments. Only if these are not sufficient or the side effects are too serious, an operation is performed.
Trigeminal neuralgia diagnosis
Not every pain in the face area is a trigeminal neuralgia. For example, temporomandibular joint problems, teeth diseases or cluster headaches may be associated with facial pain.
In order to be able to distinguish the trigeminal neuralgia against the numerous other head and face pain forms, the patient’s symptoms are carefully surveyed in a medical history discussion.
The right contact for trigeminal neuralgia is the specialist for neurology or the specialist for neurosurgery. Through targeted questions, he can already assess whether or not a trigeminal neuralgia is present. Possible questions include:
- Where exactly do you have the pain?
- How long do the pain last?
- How do you feel the pain, for example as pungent, stabbing, like a push?
- Do you have any other symptoms, such as feeling disturbed at other body parts, blurred vision, nausea or vomiting, apart from the pain?
- Do the painful attacks also make you very emotional?
Subsequently, various neurological tests can be used in the physical examination, depending on the complaints. Among other things, the doctor will pay attention to whether the sensibility (sensitivity) in the facial area is normal. Further examinations must be carried out in any case to clarify further possible trigeminal neuralgia causes.
Further investigations with trigeminal neuralgia
The magnetic resonance tomography (MRI) of the skull takes a special place in the diagnosis of trigeminal neuralgia. The nuclear spin test can be used to check whether the pain is the result of a certain cause.
The MRI provides indications as to whether a multiple sclerosis, a brain tumor, a past stroke or a vascular malformation may be responsible. These causes must be checked in each case in order to choose the right therapy form.
In the course of trigeminal neuralgia, the following investigations are sometimes carried out:
- Lumbar puncture: The extraction of nerve water from the spinal canal is used to clarify multiple sclerosis
- Computer tomography of the skull: in particular, the bony structures of the skull can be represented
- Angiography or nuclear spin-angiography (MRA): By the representation of the blood vessels of the skull in an angiography, vascular malformations can be detected. This is also useful before an operation, so that the neurosurgeon knows exactly how the blood vessels run in the surgical area
- Electrophysiological examinations
- If necessary, further examinations can be done by a dentist, orthodontist or ENT physician
Trigeminal neuralgia treatment
For treatment with trigeminal neuralgia, either drugs (pharmacotherapy) or surgery are available. The classical trigeminal neuralgia (no detectable cause for the pain) is treated primarily with medication. An operative use is only used in the event of failure of the drug therapy or of the unacceptable side effects of the medicaments.
In the case of symptomatic trigeminal neuralgia, the choice of therapy depends on the underlying cause, for example removal of the tumor, treatment of multiple sclerosis, etc.
Pharmacotherapy at Trigeminal neuralgia
The usual pain medications (such as ibuprofen, diclofenac, etc.) are usually ineffective in trigeminal neuralgia do not develop their effect until after about half an hour – too late for painful necrosis of trigeminal neuralgia which can occur at any time without warning. Therefore, a preventive therapy with special pain medication is necessary.
The active substance carbamazepine is primarily used for this purpose. This medication is also used for people with epilepsy (antiepileptic) and is the first choice for the prevention of pain attacks in trigeminal neuralgia. The dose is gradually increased until the pain attacks stop.
Operative therapy for trigeminal neuralgia
An operation can be considered if medication alone is not sufficient to relieve pain or if strong side effects of the drugs make further drug therapy impossible. Three operating procedures are available for trigeminal neuralgia.
Three surgical procedures are available for trigeminal neuralgia. All three reliably lead to a reduction in pain or complete long-term pain free. However, the pain may recur after a few years. In addition, every operation naturally also carries risks.
Before the operation, the affected person should speak in detail about the chances and risks of the intervention with the treating physician. These three operative methods are used for trigeminal neuralgia treatment.
The course of the disease in trigeminal neuralgia is very variable. It is unpredictable how much time will pass before the next pain attack. People with a trigeminal neuralgia can be completely painless for days, weeks, months or even years. In about 29 percent of those affected, it remains even with a one-time pain attack. On the other hand, pain attacks can also accumulate over the years.
Trigeminal neuralgia prognosis
The pain in trigeminal neuralgia is extremely strong. Many sufferers are severely affected by the constant fear of the next pain attack in their daily lives. For example, many sufferers avoid talking or eating for fear of trigeminal neuralgia. The strong pain is also a great burden for the emotional well-being.
In addition to drug and surgical therapy, in case of need for treatment of trigeminal neuralgia, a psychological or psychotherapeutic support should also be successful.