TRIGEMINAL NEURALGIA

Also known as
TIC DOULOUREUX PROSOPALGIA SUICIDE DISEASE NEURALGIA EPILEPTIFORME By: Aleshba Saba Roll # 17 BDS 1st Year A neuropathic disorder of trigeminal nerve

Contents
Introduction Causes, risk factors & triggers Symptoms Types of Trigeminal neuralgia Tests & diagnosis

Treatment
Prevention References

Excruciating
current-like

(INTRODUCTION)

intense pain

TRIGEMINAL NEURALGIA

Jabbing in nature

Trigeminal neuralgia (TN) is amongst the most painful conditions known. It produces brief but severe attacks of intense pain that lasts from seconds to minutes Pain is limited to the sensory distribution of trigeminal nerve that includes middle face (maxillary division V2) being most frequently involved, lower (mandibular division V3) & upper (ophthalmic division V1) being least frequently involved

Trigeminal neuralgia pain is characterized by episodes of excruciating, stabbing or electric shock-like pains, that may occur in one or more of the distributions of CN V Attacks may come on without warning (spontaneously) or be triggered by activities such as talking, eating, drinking, tooth brushing, shaving, etc

Pain of TN may occur many times per day during period of flare up (exacerbations) There are also the periods when pain disappears (remissions)

That are commonly experienced early in the course of the disease

However, virtually all patients develop progressively more severe and frequent pain attacks as well as reduced periods of remission Therefore the need for more aggressive medical or surgical treatments increases as the disease invariably progress

Causes
If nerve's function is disrupted: Usually, the problem is

contact between a normal artery or vein and the trigeminal nerve, at the base of your brain. This contact puts pressure on the nerve and causes it to malfunction
As a result of aging

Causes
Multiple sclerosis or a similar disorder that damages

the myelin sheath protecting certain nerves

tumor compressing the trigeminal nerve Shingles In most cases the cause is unknown

Tumor affecting CN V

Risk factors
Usually develops after the age of 50, although there have been cases with patients being as young as three years of age 1 in 15,000 (estimated) people suffer from TN

Women are 3 times more likely to be affected than men

Triggers that may set off the pain of TN

Shaving Stroking your face Eating Drinking Brushing your teeth Talking Putting on makeup Encountering a breeze Smiling

SYMPTOMS

Symptoms:
Occasional twinges of mild pain Episodes of severe, shooting or jabbing pain that may feel like an electric shock Spontaneous attacks of pain or attacks triggered by things like touching the face, chewing, speaking, and brushing teeth Bouts of pain lasting from a few seconds to several seconds Episodes of several attacks lasting days, weeks, months or longer some people have periods when they experience no pain

Symptoms:
Pain in areas supplied by the trigeminal nerve (nerve

branches), including the cheek, jaw, teeth, gums, lips, or less often the eye and forehead Pain affecting one side of your face at a time Pain focused in one spot or spread in a wider pattern Attacks becoming more frequent and intense over time

TYPES OF TRIGEMINAL NEURALGIA

TYPICAL

TN
ATYPICAL

PRE-TN

TN

POSTTRAUMIC

7 TYPES

TN

MULTIPLE SCLEROSIS RELATED TN

2ndary
TN

FAILED TN

1. Typical TN
Most common form of TN Minor aching or burning pain Previously been termed Classical, Idiopathic and

Essential TN Nearly all cases of typical TN are caused by blood vessels compressing the trigeminal nerve root as it enters the brain stem Caused by arteries or veins, large or small, that may simply contact or indent the trigeminal nerve

Typical TN
Pulsation of vessels upon the trigeminal nerve root do

not visibly damage the nerve. However, irritation from repeated pulsations may lead to changes of nerve function, and delivery of abnormal signals to the trigeminal nerve nucleus. Over time, this is thought to cause hyperactivity of the trigeminal nerve nucleus, resulting in the generation of TN pain.

Normal

Neurovascular compression

Typical TN
superior cerebellar artery is the vessel most often

responsible for neurovascular compression upon the trigeminal nerve root

It may be cured by medicines or micro vascular

decompression (MVD surgery)

2. Atypical TN
Characterized by a unilateral, prominent, constant and

severe aching or burning pain Vascular compression is thought to be the cause of many cases of atypical TN Can be at least partially relieved with medications MVD surgery is curative for many patients with atypical TN Rhizotomy procedures might be effective in treating

MVD

3. Pre-trigeminal neuralgia
Odd sensations of pain, (such as a toothache) or

discomfort (like pins and needles), may be symptoms of pre-trigeminal neuralgia

Pre-TN is most effectively treated with medical

therapy used for typical TN

4. Multiple Sclerosis-Related TN
1% of patients suffering from multiple sclerosis develop TN TN is more commonly seen in people with multiple sclerosis MS involves the formation of demyelinating plaques within the brain

For treatment, Trigeminal rhizotomy is employed when medications fail to control the pain
For some individuals with MS-TN, neurovascular

compression of the trigeminal nerve root may be a rare cause and is demonstrated with special MRI or CT scans

5. Secondary or tumor related TN

Caused by a lesion, such as a tumor May cause facial numbness, weakness of chewing muscles, and constant aching pain Medications usually help control secondary TN pain Surgically removing the tumor usually alleviates pain and trigeminal function may return After the removal of the tumor, the trigeminal nerve may be found to also be compressed by an artery or vein. Then MVD technique is used

Tumor

6. Post-Traumatic TN or Trigeminal neuropathy

Caused by injury to CN V

May develop following cranio facial trauma (such as

from a car accident), dental trauma, sinus trauma (such as following Caldwell Luc procedures) Numbness may become associated with sensations or pain, sometimes called phantom pain

Post-Traumatic TN or Trigeminal neuropathy

Constant, aching or burning pain, but may be worsened

by exposure to triggers such as wind and cold Pain may not be controlled with medications There are some reports of pain relief associated with the use of trigeminal nerve stimulation procedures

7. Failed TN
Unfortunately, in a very small proportion of sufferers,

all medications, MVD and destructive rhizotomy procedures prove ineffective in controlling TN pain. This condition is called failed trigeminal neuralgia

When to seek medical advice?

If you experience facial pain, particularly prolonged or recurring pain or pain unrelieved by over-thecounter pain relievers, see your doctor.

TESTS AND DIAGNOSIS

What should a doctor do?

Review medical history of the patient Ask patient to describe the pain (a) How severe it is? (b) What part of face is affected (c) How long it lasts (d) What triggers it Touches parts of face to try to determine exactly where the pain is occurring May need MRI or CT Scan

TREATMENT

There are some things that a patient can do to minimize the frequency and intensity of TN attacks:
1. Apply ice packs. Cold often numbs the area and will

reduce the pain 2.Warming packs provide relief as they stimulate blood flow to the area they are placed upon 3.Get adequate rest in normal rest cycles 4.Manage your stress well and keep stress levels low 5. Avoid foods that may act as nerve stimulants, such as coffee, tea, and foods that are high in sugar 6. Maintain adequate hydration and electrolyte levels at all time 7. Practice healthy living principles such as diet and exercise

1st step of treatment- Medications

Trigeminal neuralgia is usually treated with drugs called anti- convulsants which include:
Carbamazepine (most commonly used) Phenytoin Oxycarbazepine Gabapentin Baclophen

Half of TN sufferers eventually become dissatisfied with medical therapy, because of incomplete control of pain or drug-related side effects that are almost always experienced. Surgical treatments are then considered

Alternative treatment methods

Complementary and alternative treatments for

trigeminal neuralgia include:

Acupuncture Biofeedback

Vitamin therapy
Nutritional therapy Electrical stimulation of nerves

2nd step of treatment- Surgery

The goal of surgery is either to stop the blood vessel

from compressing the trigeminal nerve, or to damage the trigeminal nerve to keep it from malfunctioning
Damaging the nerve often causes temporary or

permanent facial numbness, and with any of the surgical procedures, the pain can return months or years later

Surgical options include:

Microvascular decompression (MVD Glycerol injection Balloon compression Electric current Severing the nerve called partial sensory

rhizotomy (PSR) Stereotactic Radiation Therapy

Microvascular Decompression Surgery alleviates neurovascular compression by placing inert shredded Teflon felt implants between compressing vessels and the trigeminal nerve root

Percutaneous Rhizotomies involve inserting a needle through the cheek and into an opening at skull base (foramen ovale). There, a controlled injury to the trigeminal nerve and Gasserion ganglion may be produced in one of three ways:

1) Percutaneous Glycerol Injection glycerol is injected into the space around the Gasserion ganglion, and chemically damages the nervous tissue.

2) Percutaneous Balloon Compression Rhizotomy - a balloon is inflated next to the Gasserion ganglion, compressing and mechanically damaging the nervous tissue.

3) Radiofrequency Rhizotomy - an electrode is advanced into the Gasserion ganglion, and heated to thermally damage the nervous tissue.

Gamma Knife Radio surgery focuses cobalt radiation upon the trigeminal nerve root, producing a delayed injury to nervous tissue that is similar to that produced by other percutaneous rhizotomy techniques.

Peripheral Trigeminal Nerve Blocks, Sectioning and Avulsions involve injuring the peripheral portions of the trigeminal nerve external to the skull.

Microsurgical Rhizotomy involves surgical exposure and cutting of the trigeminal nerve root near its entry into the brain stem.

MVD

FACTS
In one case of trigeminal neuralgia associated with

tongue-piercing, the condition resolved after the jewelry was removed

Some patients have reported a correlation between

dental work and the onset of their trigeminal nerve pain

Prevention
There are no guidelines for preventing trigeminal neuralgia. However, once you have it, steps that may help prevent attacks include:
Eating soft foods Eating food and drinking beverages that are at room temperature Washing your face with cotton pads and warm water If tooth brushing triggers attacks, rinsing your mouth with warm water after eating Avoiding or minimizing known triggers such as

heat, cold, touch, or air

THANK YOU !