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Trigeminal Neuralgia : Pain Beyond Description

Trigeminal Neuralgia : Pain ,The trigeminal (V) nerve:


The V nerve provides sensation to the face, mouth and part of the Dura, and motor supply to the muscles of the jaw involved in chewing. The cell bodies of the sensory fibers are located in the trigeminal (Gasserian) ganglion, which lies in a cavity (Meckel’s cave) in the petrous temporal Dura.



The peripheral processes of these cells give rise to the three major branches of the nerve:

  1. - Ophthalmic (V1) : supplies sensation to the skin of the upper nose, upper eyelid, forehead and scalp.

  2. - Maxillary (V2) : it contains sensory fibers from the mucous membranes of the upper mouth, roof of pharynx, gums, teeth and palate of the upper jaw and the maxillary.

  3. - Mandibular (V3) : it supplies the floor of the mouth , common sensation to the anterior two-thirds of the tongue, the gums and teeth of the lower jaw ,the skin of the lower lips and jaw area.

 

Trigeminal Neuralgia (TN) :

Also known as Tic Douloureux, is a sudden ,severe facial pain. It is often described as a sharp shooting pain or like having an electrical shock in the jaw, teeth or gums. Some people say that it is the most excruciating pain known to humanity.

What are the symptoms of Trigeminal Neuralgia ?

very severe pain usually occurs in the form of unexpected attacks of short duration that can last from a few seconds to about two minutes, and the attacks stop as suddenly as they began.
      In most cases, the pain is unilateral (on one side of the face), but in some cases, the pain affects  both sides of the face even if not at the same time. Patients may have regular episodes of pain for days, weeks or months at a time, and in severe cases, attacks may occur hundreds of times a day.
      Each time the pain occurs, it may improves or disappear for several months or years at a time. However, these periods tend to get shorter over time. Some people may then have sharp attacks accompanied by more continuous aching, throbbing or burning sensation.
      Living with this pain can be extremely difficult, as it significantly affects the quality and lifestyle of the affected person, leading to problems such as depression and anxiety.

What causes Trigeminal Neuralgia?

The pain is usually caused by compression of the trigeminal nerve, which is usually caused by a nearby blood vessel pressing on part of the nerve inside the skull, or when it is damaged by another medical conditions, such as tumors, cysts, multiple sclerosis (MS), facial injury or any medical condition that damages the myelin sheaths.
Pain triggers include all activities that involve lightly touching the face in addition to:
- Washing
- Eating
- Brushing teeth
- Shaving
- Smiling
- Talking
- Applying makeup ....... And sometimes, it can happen without a trigger.

Who is affected?

The reports showed that 150,000 people are diagnosed with TN every year. It is usually starts between the age of 50 and 60 , and rarely in adults younger than 40. The national institute of neurological disorders and stroke (NINDS) notes that TN is twice as common in women than men. 

When to seek medical advice?

  We should know that diagnosing TN cab be difficult and it can take a few years for a diagnosis to be confirmed, so that, you must see a GP if you suffer from frequent or persistent facial pain, particularly if standard painkillers, such as paracetamol and ibuprofen, do not help and there is no dental causes or any other disease that explains the condition.

Diagnosis :

As we mentioned previously, TN can be very difficult to diagnose, because symptoms are very similar to other facial pain disorders, in addition, there are no specific diagnostic tests. That is why you must see your primary care physician when you suffer from any of the symptoms above.
He may refer you to a specialist later. Magnetic resonance imaging (MRI) may be needed to make an accurate diagnosis. It can determine the presence of a tumor or MS, which in turn affects the trigeminal nerve.

  • Guidelines for diagnosing TN from the international headache society:

For classical TN:

  1. - Paroxysmal attacks of pain lasting from a fraction of a second to two minutes, affecting one or more divisions of the trigeminal nerve and fulfilling criteria 2 and 3.

  2. - Pain has at least one of the following characteristics:

  •      Intense, sharp, superficial or stabbing.

  •      Precipitated from trigger zones or trigger factors

  1. - Attacks are stereotyped in the individual patient

  2. - There is no clinically evident neurologic deficit

  3. - No attributed to another disorder

For symptomatic TN :

  1. - Paroxysmal attacks of pain lasting from a fraction of a second to two minutes, with or without persistence of aching between paroxysms, affecting one or more divisions of the trigeminal nerve and fulfilling criteria 2 and 3.

  2. - Pain has at least one of the following characteristics:

  •         Intense, sharp, superficial or stabbing.

  •         Precipitated from trigger zones or trigger factors

  1. - Attacks are stereotyped in the individual patient

  2. - A causative lesion, other than vascular compression, has been demonstrated by special investigations and/or posterior fossa exploration.

Differential Diagnosis :

       Many diseases can be similar to trigeminal pain:

  • Migraines.

  • Giant cell arteritis.

  • Post hepatic neuralgia.

  • Cluster headaches.

  • Dental pain.

  • Glossopharyngeal neuralgia.

  • Occipital neuralgia.

  • Otitis media.

  • Sinusitis.

  • Temporomandibular joint syndrome.

Treatment :

        Therapeutic procedure vary according to several factors:

  • Severity of disease.

  • Underlying causes.

  • Presence or absence of some symptoms.

  • Patient’s age.

  • His general health.

      And many other factors that are evaluated by the therapist. The initial treatment: Use of medications, especially anti-convulsants (carbamazepine or oxycarbamazepine) which is very effective when used in the early stages of the disease. We start with a low dose and gradually increase until the complete absence of pain. Despite its initial effectiveness, the benefits of these drugs may lessen over time.
      Another anti-convulsants medications that have been used to treat TN in smaller studies or case reports include: - gabapentin.
-topiramate.
-valproic acid.
-phenytoin. 
-clonazepam. 
-lamotrigine. 
- pregabalin.
      Over time these drugs become less effective in many cases, then, changing to another type or sharing more than one type together is recommended. Muscle relaxants, such as baclofen, may also be used either alone or in conjunction with anti-convulsants medications. another drug group , tricyclic antidepressants, such as amitriptyline and nortriptyline, in addition to common pain reliever such as opioids can be used in special cases.
      Surgery is another solution for TN , it is required if the medications are not sufficient to control the pain, especially in an individual who does not have an adequate response to the two front-line medications, whether these medications are used succession or in combination.
      There are two types of surgical treatment:

  1. - Open cranial surgery: it is thought to take away the underlying problem causing the TN.

  2. - Lesioning procedures: this type may be shorter lasting and sometimes may result in numbness of the face.