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Trigeminal neuralgia symptoms, causes, and treatment.

Trigeminal neuralgia is a condition in which the trigeminal nerve is affected. In the following article, you will learn everything about it. 

Trigeminal neuralgia is a chronic pain condition that affects the 5th cranial nerve: trigeminal nerve. Attacks of intense facial pain characterize the disease. It commonly affects 1.5 in 10.000 people in the US every year, affecting women twice as much as men. Also, around 90% of patients diagnosed with TN are older than 40 years old. 

This reading aims to answer all the questions you may have about trigeminal neuralgia; everything you need to know from the disease, like what causes it, the symptoms, as well as and diagnosis and treatment. The best part is that they get their answer from a real doctor, but with the simplest words. This way, any person who reads this article will learn something new in no time. 

What is trigeminal neuralgia?

Trigeminal neuralgia (TN) is a common chronic condition in which there is pain coming from the trigeminal nerve. Sometimes doctors categorize it as a disabling pain syndrome. 

The pain is often unilateral and follows the sensory distribution of cranial nerve V (trigeminal nerve). In more than 35% of the cases, the pain radiates to the maxillary or mandibular area (all the face below the eyes area). 

Most of the time, it is accompanied by a tic or a facial spasm. The exact way trigeminal neuralgia happens is not fully understood, and many theories try to explain this condition. 

Despite the latter, doctors have classified the pain of TN as neuropathic pain. This means that the pain is mainly because of damage or a disease that affects your somatosensory nervous system. This is the part in charge of sending signals of sensations to your brain. 

What is the trigeminal nerve, and what causes trigeminal neuralgia?

The trigeminal nerve is the largest of the cranial nerves. It is the fifth cranial nerve from twelve, and it comes from a structure of your CNS called the pons. 

File:Trigeminal Nerve.png
Source

From there, it divides into two trigeminal nerve roots: a small motor root (for movement) and a larger sensory root. This division explains why the trigeminal nerve is mostly a sensory nerve. 

These roots form the Gasserian ganglion from where the trigeminal nerve divides into 3 branches: ophthalmic (V1), maxillary (V2), and mandibulary (V3). In most cases, the trigeminal neuralgia pain will radiate to the maxillary or the mandibular nerve. 

Sadly, the exact cause of trigeminal neuralgia is not fully understood. Doctors have yet to find out if the origin of trigeminal neuralgia is central, peripheral, or both. 

In almost 85% of TN patients, there is no structural damage of the nerve. However, many doctors agree that vascular compression of the trigeminal nerve root may be a cause of TN. This means that a blood vessel can compress the trigeminal nerve, causing the symptoms. 

Moreover, another reason can be the loss of myelin (coverage of the nerves), affecting the way nerves conduct signals. In a less common approach, there can also be tumor-related and inflammatory causes. 

The doctor divides trigeminal neuralgia into two categories: classic TN and symptomatic TN. The classical trigeminal neuralgia, or idiopathic trigeminal neuralgia, includes the cases due to contact between an artery and the trigeminal nerve. However, there is no nerve fiber damage or severe compression. The symptomatic form of TN can have multiple origins like aneurysms, tumors, and chronic inflammation. 

What triggers a trigeminal neuralgia attack?

When you suffer from trigeminal neuralgia, almost every touch stimulus can trigger a pain attack. Among the most common activities that trigger TN pain we find: 

  • Putting on makeup
  • Eating or drinking
  • Shaving or touching your face
  • Talking
  • Brushing your teeth or washing your face
  • Touching your face
  • Encountering a breeze

The triggering of the pain from these activities is an important detail to make the diagnosis of TN. In other conditions that cause facial pain, patients may massage the area or put ice in it for relief. In the case of trigeminal neuralgia, patients will avoid touching their faces at all costs to prevent pain. 

What are the risk factors?

Since the cause of trigeminal neuralgia is unclear, it is very difficult to identify possible risk factors for it. So far, doctors have identified that patients with other neurological disorders, like multiple sclerosis have an increased risk of TN

The latter also includes patients with a medical history of strokes. For example, vascular conditions like hypertension, arteriosclerotic vascular changes, and arteriovenous malformations increase the risk of potential compression of the trigeminal root. 

In addition, genetics, age, and race can contribute to a higher chance of developing TN. Some patients can have a particular sensitivity to develop many forms of neuralgia. In some studies, doctors have found that stress can also act as a risk factor for idiopathic TN. 

There is a specific type of TN, “postherpetic neuralgia“. As you may guess by its name, postherpetic neuralgia can occur after having a herpes infection. The herpes virus can cause inflammation of the nerves and can cause trigeminal neuralgia as a sequel. 

What does trigeminal neuralgia pain feel like? 

Patients who suffer from trigeminal neuralgia will likely describe it as a stabbing, intense pain. It is unilateral (just one side) and is triggered by certain activities or touch of the face

The localization of the pain is an important characteristic. It is more likely to affect the right side than the left side, and patients can easily identify its localization. 

The pain will not be exclusive of one branch of the trigeminal nerve. In fact, it is more likely that the pain runs along the line and divides the maxillary and mandibular nerve. Most patients also describe it as a lancinating pain from the corner of their mouth to the angle of the jaw. Around 1/3 of patients describe pulses of pain from the upper lip to the eye and eyebrow.

The pain quality is important. Both patients and doctors agree that severe, lancinating (stabbing sensations), and paroxysmal (sudden increase or recurrence) pain are the best words to describe it

The pain can start suddenly, with sensations of electric shocks that quickly become excruciating pain. After an attack, the intense pain decreases and leaves a burning ache and facial numbness that can last for minutes. 

Unlike other facial pain conditions, the pain of TN is not chronic pain. However, some patients experience episodes of recurrent pain. A patient who suffers from TN can have only 1 attack per day or as much as 12 per hour. 

What can be mistaken for trigeminal neuralgia?

Many conditions can cause facial pain. However, the facial pain of trigeminal neuralgia can be easily distinguished from the pain that the following conditions cause: 

  • Cavernous sinus syndromes
  • Cerebral aneurysms 
  • Cluster headaches
  • Glossopharyngeal neuralgia
  • Hydrocephalus
  • Migraine headache
  • Multiple sclerosis
  • Postherpetic neuralgia
  • Brain hemorrhages

How many people get trigeminal neuralgia? 

As of today, trigeminal neuralgia can be considered a common condition. In the US, data estimates that 1.5 in 10.000 people suffer from trigeminal neuralgia. 

The incidence (number of new cases of a disease) is around 15.000 new TN cases every year. Also, you must know that women suffer from trigeminal neuralgia twice as much as men

Approximately 90% of patients will have the start of the disease after forty years. The average age of symptoms onset is between 60 and 70 years of age. 

How does trigeminal neuralgia progress?

After the first attack, trigeminal neuralgia will probably remit for months or even years. They will typically get more frequent, more intense, and disabling. 

Furthermore, later on, attacks can be more easily triggered and may require long-term medication. When trigeminal neuralgia gets worse, patients may experience other symptoms like depression and loss of daily functioning. 

The latter especially happens when patients don’t receive any treatment or medical assistance. This disease is likely to persist over time and become a chronic pain syndrome

Importantly, the disease can limit activities that can potentially trigger pain, like chewing, shaving, or even talking. In a small fraction of patients, the pain can be so intense or unbearable that they chose suicide to escape the pain. Still, luckily, nowadays exist several treatment options to avoid the recurrence of these painful attacks. 

How is trigeminal neuralgia diagnosed?

If you think you may be suffering from trigeminal neuralgia, you should visit your doctor right away:

  1. The doctor will ask a detailed question about your medical history. Later, they will ask questions about the symptoms you’ve been experiencing. Try to describe the pain the best possible since this part is crucial to establish a diagnosis.
  2. He or she will perform the physical examination.
  3. Later on, the doctor may want to complement the diagnosis with laboratory tests or imaging studies with the diagnostic presumption.

In the case of trigeminal neuralgia, no laboratory or radiologic testing is indicated for making a diagnosis. In fact, the diagnosis of facial pain depends almost entirely on the patient’s history. 

However, imaging studies can be useful to establish a definite diagnosis, especially to distinguish classic and symptomatic forms of trigeminal neuralgia. 

In the latter case, the most useful study is magnetic resonance imaging. With an MRI, doctors can observe inside your body in order to identify what’s causing the trigeminal neuralgia. With this imaging study, doctors can see if you have a neurovascular compression causing you pain. 

How is it treated?

Like we mentioned before, there are multiple ways to treat trigeminal neuralgia. Most of the time, trigeminal neuralgia is treated with an outpatient approach unless the patient needs surgery. A trained medical professional must decide the right treatment approach for your individual case. 

What treatment options exist for trigeminal neuralgia?

There are four main approaches to treat TN:

  • Medical treatment
  • Surgical treatment
  • Percutaneous procedures
  • Radiation treatment.

Medical treatment

Fortunately, medical therapy alone can be enough in order to treat trigeminal neuralgia patients. More than 75% of patients with TN will get better with medical treatment alone. If this approach fails, then your doctor may consider changing to the surgical approach of TN treatment. Among the elected drugs to treat trigeminal neuralgia we find the antiepilectic drug like carbamazepine, gabapentin or lamotrigine. 

The preferred drug for this condition is carbamazepine in the first line of treatment. This, because this drug alone has shown important improvement in the patients that take it. In fact, a significant group of patients will experience remission of the pain with only medical treatment with carbamazepine. However, in those patients where carbamazepine is not enough, the combination of different drugs is advised to manage the pain. 

Surgical treatment

Over time, the medical treatment for trigeminal neuralgia will lose effectiveness. More than ¼ of the patients will stop reacting to medical therapy. For patients that no longer benefit from medical treatment, a surgical approach is recommended. Besides, surgery is a definite treatment for people younger than 60 years old with TN. 

Doctors divide surgical therapy according to the localization of the procedure. There are three most practiced techniques nowadays: 

  • Percutaneous procedures: They can be performed on an outpatient basis. The most commonly practiced is radiofrequency rhizotomy. This procedure works by destroying the part of the nerve that causes pain and stopping the signal of pain to your brain. This is done with an electrode that heats up the nerve fibers in order to destroy them. 
  • Gamma knife radiosurgery: Consists of multiple rays of high-energy photons concentrated on the target. This destroys specific components of the nerve. Around 60% of patients become pain-free right after the procedure. 
  • Vascular decompression: Commonly performed in young patients with pain in the ophthalmic division or in all 3 divisions of the nerve. It is the most common surgery to treat trigeminal neuralgia. It consists of freeing the trigeminal nerve from the compression with the artery and putting a piece of Teflon between them. In order to do this, the doctor will open a keyhole in the area of the mastoid to access the nerve. 

What can you do if you have trigeminal neuralgia? 

The best thing you can do if you experience trigeminal neuralgia pain is to look for medical assistance. This way, you can get your diagnosis and treatment as soon as possible to stop the unbearable pain

As you can see, there are many treatment options for TN. Thanks to this, it shouldn’t be a problem to find a therapeutic approach that suits your needs. 

Still, pearls to take home include the recommendation of avoiding as much as you can all the activities that may trigger an attack. Don’t worry; this will only be for a bit of time while you get the treatment and medical help you need. 

Do you have symptoms of this disease?

This tool is a Trigeminal Neuralgia Symptoms Checker. It gathers the most important signs, symptoms, and risk factors for the disease. Therefore, the tool would tell anybody who uses it the likelihood of having Trigeminal Neuralgia. Using the tool is free and would only take a few minutes.

What do you think?

Written by Dr. Esteban Kosak

Doctor of Medicine - MD Recently Graduated from Medical School and inspired to aid the global population during this situation. I think that we shall no longer be waiting to see a doctor when we feel sick. Several times we feel disease searches in Google drive us to a rabbit hole and come out thinking that we may die of cancer or something very serious, given that symptoms may seem to fit a wide variety of illnesses. Since I recently graduated from medical school. I have all the medical information fresh in my mind. My thorough experience as an expert researcher allows me to very-well known the different diseases and conditions that affect human bodies. Empowered by the United Nations 17 Sustainable Development Goals (SGDs). I think that we all can provide a grain of sand to help humanity. That's why we created Symptoms.Care a place where you can come and screen your symptoms and find what different illnesses can be related to them. Armed with the right information you can instantly, discretely, secure and from the comfort of your home talk with a Doctor that can Evaluate your Symptoms and help you seek the right treatment.

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