Trigeminal Neuraglia: Symptoms, Causes and Treatment

Trigeminal neuralgia (TGN) refers to a sudden attack of intense, stabbing, shock-like facial pain, lasting seconds, in the territory of trigeminal nerve, typically affecting the mandibular and maxillary divisions of trigeminal nerve. It is unilateral, usually affecting the patients above 50. It is also called "tic doloureux" as the face screws up with pain during the attack. Characteristically, pain starts near one side of the mouth (angle of mouth) or from the upper lip and shoots toward ear, eye or nostril of the same side, sparing the orbit itself. 

Triggers:

Touch and movement trigger TGN. Thus, washing the affected area, shaving, brushing, talking, smiling, eating, drinking, putting-up makeup, dental prostheses, and even drafts (air currents) leads to TGN. It pains when you kiss or smile! Paroxym of pain rarely occurs at night when the sufferer is asleep.

Causes:

Anything that harms trigeminal nerve (fifth cranial nerve, CN-V), may cause TGN, especially the anomalous intracranial vessels compressing the trigeminal root. Aneurysms, tumours, multiple sclerosis, herpes zoster, chronic meningeal inflammation, skull base malformation are some secondary causes of trigeminal neuralgia.

Investigations:

Most often, the diagnosis is clinical. MRI is justifiable for secondary causes of TN.

Differential Diagnosis:

• Cluster headache 
• Chronic paroxysmal hemicrania
• Cracked tooth syndrome
• Jabs and jolts syndrome
• Post‐herpetic neuralgia
• Giant cell arteritis (temporal arteritis)
• SUNCT (Short‐lasting, unilateral, neuralgiform headcahe with conjunctival injection and tearing) 

Source: http://bja.oxfordjournals.org

 

Treatment:

Trigeminal neuralgia treatment mainly comprises of pharmacological therapy; however, surgical procedures are also considered in some cases.

Medical:

Carbamazepine (Tegral, Teril) - start with 100mg per oral, twice a day; maximum dose is 400mg six hourly.

Lamotrigine (Lamictal, Lamnet, Lojin) - start with 25mg once or twice daily; increase slowly up to 250mg twice daily.

Phenytoin (Dilantin)- 200-400mg per oral, daily, before meals; maximum dose is 600mg per oral daily.

Gabapentin (Gaba, Gabix, Neurontin) - Start with 300mg once a day at day 1, twice a day at day 2 and thrice a day at day 3. Usually, 300-600mg per oral, thrice a day; maximum dose is 2400mg per day. Usually, it is given in addition to Carbamazepine. It is tried in those cases which do not respond to conventional therapy or those suffering from multiple sclerosis.

Pregabalin (Lyrica, Gabica, Zeegap, Regab, Pegalin) - 50-100mg, per oral, thrice a day; may be increased up to 600mg daily in 2-3 divided doses.

Baclofen (Lioresal)- start with 5mg per oral thrice daily; increase dose of 5mg at 3 days intervals; maximum dose is 100mg per oral daily.

Surgical:

If drug treatment fails, surgery of peripheral nerve, the trigeminal ganglion or the nerve root may be necessary. Microvascular decompression is a surgical procedure where anomalous vessels are separated from the trigeminal root. Other surgical procedures include gamma knife radiosurgery, glycerol injection, balloon compression and radiofrequency thermal lesioning.

Alternative Therapy:

Alternative therapy includes acupuncture, biofeedback, vitamin therapy, nutritional therapy and electrical stimulation of nerves.

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Keywords: Trigeminal neuralgia, Facial pain, Tic doloureux, Microvascular decompression, Carbamazepine,Fifth cranial nerve, Trigeminal nerve,