Trigeminal neuralgia or facial neuralgia is the disease or overstimulation of the 5th cranial nerve. The symptoms are severe seizure-like pain in the face. Treatment is initially with medication, and in severe cases, surgery may be necessary.
What is trigeminal neuralgia?
Trigeminal neuralgia is a disease of the trigeminal nerve. It innervates the face, masticatory apparatus and pharynx with its three branches (trigeminal = triplet) and is directly connected to the brain. It belongs to the 12 cranial nerves and is called the 5th cranial nerve. Neuralgia is the medical term for nerve pain (neuron = nerve, -algia = pain). Trigeminal neuralgia manifests itself as seizure-like pain in the cheek, upper and lower jaw, as well as on the forehead, around the eye or in the sinus. A distinction is made between symptomatic and classic trigeminal neuralgia. The less common symptomatic form occurs as an accompaniment to other underlying diseases, often in multiple sclerosis or after a stroke. It often develops bilaterally. Classic trigeminal neuralgia is the more common type. It usually forms on one side only and is characterized by symptom-free intervals.
Causes
The cause of trigeminal neuralgia is damage, overstimulation, or disease of the 5th cranial nerve (trigeminal nerve). In classic trigeminal neuralgia, the trigger is usually increased pressure on the nerve. This is caused by thickened blood vessels. When arteries are calcified, their elasticity decreases and they become thick and immobile. Now, if such a thickened artery is close to the nerve, it creates pressure, causing irritation or damage to the nerve. In the less common symptomatic trigeminal neuralgia, the cause is another disease. In multiple sclerosis, the nerves become inflamed, triggering trigeminal neuralgia; in stroke, impaired blood flow to the brain can cause the neuralgia.
Symptoms, complaints, and signs
The main symptom of trigeminal neuralgia is a severe pain in one side of the face that shoots in suddenly and pulls. It feels almost like a lightning-like surge of electricity that subsides after a short time. Sometimes the pain is also perceived as burning or stabbing. Depending on which branch of the trigeminal nerve is affected, the symptoms are located in the corresponding area of the face. Most often, the second and third branches become diseased. This leads to pain in the cheeks, zygomatic bone and chin, nose or upper and lower jaw. The teeth can also hurt. Rather rare, on the other hand, are complaints in the forehead, where the first nerve branch runs. The pain attacks can be triggered by touching the skin, by a draft of air, by brushing the teeth, by movements of the jaw when speaking or chewing, or by swallowing. However, they can also flare up completely unexpectedly and without any prior stimulus. Sometimes the shooting pain is accompanied by twitching of the facial muscles. The trigeminal nerve is one of the thickest nerves in the body, so the triggered pain is almost unbearable. Due to fear of a pain attack, some patients refrain from eating food and drinking fluids. This can cause weight loss and dehydration. Because the discomfort is extremely distressing, the condition can lead to depression.
Diagnosis and course
The symptoms of trigeminal neuralgia are mainly manifested by sudden onset of severe pain in the face that lasts for only a few seconds and then subsides. They feel like surges of electricity and may recur in several short intervals and then disappear again for a period of time. Often, these pain attacks are triggered by touching the face or moving the jaw. It can happen while chewing or swallowing, while brushing teeth, or even while speaking. Sometimes the attacks are also triggered by a draft of air. The pain of trigeminal neuralgia is some of the most severe pain there is. Sufferers often avoid eating or talking, as this triggers the pain attacks. To definitively diagnose trigeminal neuralgia, the physician must first ask about the patient’s medical history and perform a neurological examination. Dental, orthopedic and ENT examinations can be performed to rule out other diseases that cause similar pain.Magnetic resonance imaging (MRI) can detect previous strokes, tumors, or inflammation that may be the trigger for trigeminal neuralgia.
Complications
Extremely painful trigeminal neuralgia can result in several complications. These are usually classified as postoperative complications. Because of the seizure-like and severe pain, those with trigeminal neuralgia may suffer from pain-related depression. Apart from the medical treatment goal of achieving permanent pain relief, psychotherapeutic interventions are sometimes necessary. If the pain attacks of trigeminal neuralgia cannot be relieved with medication – or if these have too strong side effects – surgical methods are common. The formerly performed transection of the trigeminal nerve usually resulted in partial facial paralysis. Since this surgical method often caused more pain than before, this treatment method has been abandoned. However, even the surgical methods used today are not without risk. In symptomatic trigeminal neuralgia, the potentially possible complications may be characterized by the underlying disease. These may be cancer or multiple sclerosis. Corresponding complications such as metastasis, paralysis or blindness are conceivable. After operations on the ganglion gasseri, pressure sensitivity, sensory disturbances or even more severe pain may occur. However, these are usually permanent pains. With microvascular decompression, there are higher risks of complications in addition to increased risks of anesthesia. Occasionally, the procedure results in unilateral hearing loss, hemorrhage, or cerebellar swelling. Radiotherapy of the irritated trigeminal nerve with a linear accelerator has comparatively fewer complications. The success rate is significantly lower.
When should you see a doctor?
Because trigeminal neuralgia is accompanied by massive facial pain, the individual should see a doctor quickly. The latter must determine whether there was a specific trigger or whether the condition is idiopathic trigeminal neuralgia. In the symptomatic variant of trigeminal neuralgia, the triggering underlying problem must be determined as soon as possible. Only then can a targeted treatment begin. In the course of this treatment, the massive facial pain can also disappear. A quick visit to the doctor is also advisable because a late complication of shingles, a tumor or multiple sclerosis can be hidden behind the severe pain symptoms in the facial area. Stroke symptoms or Lyme disease have also been identified as triggers of symptomatic trigeminal neuralgia. Tumors are rarely the triggers of trigeminal neuralgia. However, if they are, the tumors may be benign or metastatic extensions of an as yet undetected tumor. In sum, the possible triggers are serious enough that trigeminal neuralgia should not be endured for months under self-prescribed pain medications. That being said, the pain of trigeminal neuralgia is often massive. Therefore, going to the doctor often happens on its own.
Treatment and therapy
Trigeminal neuralgia is initially treated with pain medications. The usual pharmacy drugs are ineffective here, however, because the pain is extremely severe. If a very large number of pain attacks occur in succession over a short period of time, intravenous treatment with a high-dose antiepileptic drug is used. For this therapy in the case of an acute attack, inpatient admission to a hospital is necessary. To prevent the pain attacks, antiepileptic drugs are administered as tablets in lower doses, but permanently. If other underlying diseases are present, they must be treated first and foremost, since they are the triggers for trigeminal neuralgia. If there is no improvement with drug treatment, surgery is an option. In this case, the skull bone is opened in a surgical procedure to free the nerve from constricting vessels. Another treatment option that does not require surgical opening of the skull is radiosurgical therapy. Here, the nerve is treated through the bone with radiation. A third option for the treatment of trigeminal neuralgia is percutaneous (through the skin) thermoagulation, in which a probe is pushed to nerve cells of the trigeminal nerve under short anesthesia, where heat is used to destroy the pain fibers of the nerve.
Prevention
There is no way to prevent trigeminal neuralgia. However, one can prevent arteriosclerosis, which is often the cause of trigeminal neuralgia, by eating a balanced diet and maintaining a healthy lifestyle.
Follow-up
If trigeminal neuralgia is treated by surgery, follow-up care is required. In most cases, symptoms improve immediately after surgery. For control purposes, a computed tomography (CT) scan is usually performed on the day of surgery. This allows the doctor to diagnose possible air pockets or postoperative bleeding. The patient spends the first five to six days after the operation in the hospital. After that, he or she is usually discharged. Outpatient care is usually sufficient to remove stitches or staples. There are usually no restrictions after the hospital stay. Health impairments no longer exist in most patients after discharge. The painkillers that the patient has been taking up to now are to be reduced step by step in consultation with a neurologist or pain therapist. Supportive care is provided by the therapist. In rare cases, discomfort in the scar area, headaches, fever or the discharge of a clear fluid from the nose occur after the operation. In this case, the patient must consult a neurosurgeon. There is no need to start rehabilitation. It usually takes about three to four weeks before the patient is allowed to resume sports activities. During this period, stays in the sauna or in the blazing sun should also be avoided, as otherwise dizziness or headaches may occur.
What you can do yourself
The possible self-help measures for trigeminal neuralgia are limited. They extend to supporting medical treatment and are general in nature. For example, avoiding stress and eating a balanced diet contribute to well-being. Some patients rely on autogenic training or other relaxation techniques. Others have cut back on work and have integrated rituals that allow time out into their day. Regular exercise is also considered an important factor in mitigating a recurrence of pain. The consumption of nicotine and alcohol should be completely stopped. These measures do not necessarily prevent all complaints. However, they do make the symptoms seem less burdensome due to an increased sense of well-being. The everyday life of those affected is severely impaired, as the attacks can recur. Some patients suffer from chronic anxiety. This often results in a withdrawn life without activities. As a consequence, depression often sets in. Escaping this state can be difficult. A strong environment and social contacts promise a positive way to deal with trigeminal neuralgia. Contact with like-minded people sometimes helps as well. In self-help groups, experiences and tips for coping with everyday life can be exchanged.
