Brief overview
- Treatment: medication or surgery with radiation if necessary, possibly supplemented by psychological care
- Symptoms: Flash-like, very brief and extremely severe attacks of pain in the face, often with even a light touch, talking, chewing, etc. (episodic form) or persistent pain (constant form)
- Causes and risk factors: Often an artery pressing on the nerve (classic form), other diseases (secondary form), unknown cause (idiopathic form)
- Prognosis: Pain can be controlled with therapy, but cannot be permanently eliminated.
What is trigeminal neuralgia?
The condition is not very common overall, with estimates of about four to 13 people per 100,000 affected. Trigeminal neuralgia can occur at any age, but it is most common in people over 60.
Doctors distinguish between classic, secondary and idiopathic trigeminal neuralgia.
Trigeminal neuralgia: Therapy
Basically, trigeminal neuralgia can be treated either with medication or surgery.
Trigeminal neuralgia, regardless of its form, is primarily treated by doctors with medication. The focus is on eliminating the symptoms.
The fact that the causes of facial pain are not fully understood complicates trigeminal neuralgia therapy. If the right treatment is found, the pain can be alleviated well, but never completely or forever “stopped”.
Medications for trigeminal neuralgia
Active ingredients such as carbamazepine and oxcarbazepine are used here. Often, the muscle-relaxing agent baclofen also helps. If possible, the doctor prescribes only one active substance alone for trigeminal neuralgia (monotherapy). In cases of severe pain, however, two drugs may be useful (combination therapy).
Doctors sometimes treat acute pain as an inpatient in the hospital with the active substance phenytoin.
Surgery for trigeminal neuralgia
In principle, there are three surgical options for trigeminal neuralgia:
Classical surgical procedure (microvascular decompression according to Jannetta).
This method is used in healthy people with a low surgical risk. Through an opening in the back of the head, the physician places a Goretex or Teflon sponge between the nerve and the vessel. This is to prevent the trigeminal nerve from coming under pressure again.
Possible side effects or risks of the operation include bleeding, injury to the cerebellum, and loss of hearing and facial numbness on the affected side.
Percutaneous thermocoagulation (according to Sweet)
The success rate immediately after surgery is high: about 90 percent of patients are initially pain-free. However, this success only lasts permanently in about one in two.
A possible side effect is a sometimes painful loss of sensation on the affected side of the face.
Radiosurgical procedure
If this procedure is performed without previous other operations, more patients are pain-free after the procedure than if another operation has already taken place beforehand. Overall, the effect of the therapy usually occurs only after a few weeks, i.e. significantly later than with the other procedures.
Alternative treatment methods and home remedies
Some people are convinced that, in addition to the classic medical treatment methods, alternative methods such as homeopathy help in the therapy of trigeminal neuralgia. Likewise, there are various herbal painkillers or home remedies such as an infrared light lampto treat especially the pain that is typical in neuralgia.
Experts from the German Society for Neurology (DGN) also advise against vitamin preparations that contain vitamin B1 or vitamin E, for example. Vitamin preparations are often advertised as alleviating neuropathies, which include trigeminal neuralgia. However, there are no medical studies to support this.
Trigeminal neuralgia: symptoms
Characteristic of trigeminal neuralgia is pain in the face that is
- start suddenly and in a flash (attack-like),
- last for a short time (fractions of a second to two minutes).
Trigeminal neuralgia pain is one of the most severe pains of all. In some cases, they repeat up to a hundred times a day (especially in the classic form of the disease). The severe, shooting pains usually trigger a reflexive twitching of the facial muscles, which is why doctors also refer to the condition as tic douloureux (French for “painful muscle twitch”).
- Touching the skin of the face (with the hand or by the wind)
- Speaking
- Brushing teeth
- Chewing and swallowing
Out of fear of a pain attack, some patients eat and drink as little as possible. As a result, they often lose (a dangerous amount of) weight and develop fluid deficiency.
Sometimes all three branches of the trigeminal nerve or both halves of the face are affected and there are no pain-free phases between the attacks – in other words, there is constant trigeminal neuralgia (according to ICOP: type 2) with continuous pain.
In addition, some sufferers experience sensory disturbances (e.g., tingling, numbness) in the area supplied by the trigeminal nerve.
Trigeminal neuralgia: Causes
Depending on the cause, the International Headache Society (IHS) classifies trigeminal neuralgia into three forms according to the International Headache Classification (ICHD-3):
Classic trigeminal neuralgia
In addition, there is usually more than just contact between the vessel and the nerve: in classic trigeminal neuralgia, the affected artery also displaces the nerve, further irritating it and causing facial nerve inflammation and dysfunction.
Secondary trigeminal neuralgia
- Diseases in which the protective sheaths of the nerve fibers (myelin sheaths) in the nervous system are destroyed (“demyelinating diseases”): e.g. multiple sclerosis (MS).
- Brain tumors, especially so-called acoustic neuromas: these are rare, benign tumors of the auditory and vestibular nerves. They press on the trigeminal nerve or an adjacent blood vessel so that both are pressed against each other. This can additionally lead to trigeminal nerve inflammation and triggers the pain.
- Vascular malformations (angioma, aneurysm) in the area of the brain stem
Patients with secondary trigeminal neuralgia are on average younger than people with the classic form of the disease.
Idiopathic trigeminal neuralgia.
In idiopathic trigeminal neuralgia, which occurs much less frequently, no other disease or tissue change in involved vessels and nerves can be identified as the cause of the symptoms (idiopathic = without known cause).
Trigeminal neuralgia: examinations and diagnosis
Not every pain in the facial area is trigeminal neuralgia. For example, temporomandibular joint problems, diseases of the teeth or cluster headache also trigger pain in the face.
The first step when trigeminal neuralgia is suspected is to take the patient’s medical history: The physician asks the patient in detail about his or her complaints. Possible questions are:
- Where exactly do you have pain?
- How long does the pain last?
- How do you feel the pain, for example as sharp, pressing, like a surge?
- Do you have other complaints in addition to the pain, such as sensory disturbances in other parts of the body, visual disturbances, nausea or vomiting?
The doctor then performs a physical examination. He will check, for example, whether the sensation (sensitivity) in the facial area is normal.
Further examinations then clarify whether or not a triggering disease underlies the trigeminal neuralgia. Depending on the symptoms, the doctor performs one or more of the following examinations:
Extraction and analysis of the cerebrospinal fluid: Using a thin, fine hollow needle, the doctor takes a sample of the cerebrospinal fluid (CSF) from the spinal canal (CSF puncture). In the laboratory, specialists examine whether the patient has multiple sclerosis.
Computer tomography (CT):With this, doctors primarily examine the bony structures of the skull. Any pathological changes are a possible cause of the pain attacks.
Electrophysiological examinations: These include, for example, trigeminal SEP (checking the functioning of sensitive nerve pathways, for example touch and pressure sensation), checking, for example, eyelid closure reflex and masseter reflex.
Other examinations: Further examinations may be necessary, for example, with a dentist, orthodontist or ENT specialist.
Trigeminal neuralgia: course and prognosis
In about one third of those affected, it even remains with a single attack of trigeminal neuralgia. In most people, the attacks occur only now and then at first, but accumulate over time. If the attacks increase or occur frequently in succession, it is to be expected that these sufferers will be ill for a correspondingly longer period and will be unable to work for this time.
With the right treatment plan, the pain of trigeminal neuralgia can be reduced or banished, at least for a while. However, the disease cannot be completely cured at present. It is also not yet known whether and how trigeminal neuralgia can be prevented.
