TRIGEMINAL NEURALGIA THE UNENDING PAIN

8 min


INTRODUCTION:

Pain is a multifaceted experience that involves physical, cognitive, and emotional aspects. According to IASP (International Association for the study of pain), it’s defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage. There are many types of pain. One among them is orofacial pain (OFP) which is prevalent in 23% of the population. Moreover, the most common type of orofacial pain is trigeminal neuralgia, which is one of the most painful conditions.

THE TRIGEMINAL NERVE:

Before moving on to the topic, we should know about the trigeminal nerve. It is the fifth cranial nerve. Moreover, its function is to transmit sensory information to the skin, sinuses, and face. Further, it has three branches the ophthalmic branch, maxillary branch, and mandibular branch. These branches carry sensory information.

WHAT IS TRIGEMINAL NEURALGIA?

To put it in simple terms, neuralgia refers to severe pain along the course of a nerve. Trigeminal neuralgia is a long-term neuropathic disorder, which affects the trigeminal nerve, one of the most wide-reaching nerves in the head. Therefore, the nerve is responsible for sensations like biting, chewing, etc.

Defined as archetype of orofacial pain, characterized by excruciating , short–lasting ,unilateral facial pain .

HISTORY OF TRIGEMINAL NEURALGIA:

The first case was in 1671. A German physician Johannes discovered it. He had a severe lightning type of pain in his right side face. John Fothergill discovered trigeminal neuralgia. He described it as a painful condition affecting the face. And so presented this to London medical society in 1773.

ETIOLOGY:

The exact aetiology is unknown and still remains controversial. One theory suggests that injury to the trigeminal nerve results in this condition. Therefore, compression of trigeminal roots may cause pain. Factors like abnormal blood vessels, aneurysms (localized swelling), inflammation, tumours may also compress the trigeminal nerve.

CLINICAL FEATURES OF TRIGEMINAL NEURALGIA:

There will be unilateral headache, tingling sensation initially. Patients often experience sharp, shooting type, stabbing type of pain. This type of pain often described as a thunderstorm type of pain, which occurs in remission. Trigger zones, latency period, and refractory period are the most important terms in this condition.

TRIGGER ZONES OF TRIGEMINAL NEURALGIA:

While touching the face, nose, eye areas patients suddenly experience the stabbing type of pain. These zones are termed trigger zones or trigger points. Therefore, this is the classical feature of this disease. Hence, this feature differentiates from other diseases. And so, this occurs in classical types of trigeminal neuralgia.

LATENCY PERIOD:

It refers to short period of time between stimulation of a trigger area and pain onset.

REFRACTORY PERIOD:

It occurs following an attack and during this time pain may not be initiated. Therefore termed as refractory period.

DIAGNOSTIC CRITERIA:

  • Paroxysmal pain (shooting type of pain) lasts for 2 minutes.
  • Pain aggregates by touching the trigger zones (by touching the face, eyes, nose).
  • Pain has any one of the characteristics:

Stabbing, lancinating type of pain

Dull throbbing type of pain.

Hence, these criteria differentiates this condition from other.

AGE GROUP:

This is more common in the age group above 50 years. Females are more affected than males (3:2 ) ratio. The right side of the face gets affected in the majority of the patients.

OTHER NAMES OF TRIGEMINAL NEURALGIA:

  • Tic douloureux
  • Trifacial neuralgia
  • Fothergill`s disease.
  • Suicide disease (due to severe stabbing lancinating pain, patients have suicidal thoughts)
  • Prosopagia (facial pain)

EPIDEMIOLOGY:

The annual incidence of this condition has been reported in the united kingdom as 26.8 per 100,000. However, Netherlands has a lower incidence.

Recent evidence suggests that the classical type is more common. About 85% of cases fall under this type.

TYPES OF TRIGEMINAL NEURALGIA:

There are two types of trigeminal neuralgia,

TYPICAL OR THE CLASSICAL (TYPE 1):

It is the most common type. Patients have unpredictable episodes of stabbing, electric shock-like pain in a particular location. The pain aggravates by touching a trigger point on the face, also known as the trigger zones. This is the classical feature of this disease.

Trigger zones are located near the eyes, cheeks and nose. These zones when triggered causes pain.

These patients when they are exposed to cold air, exposed to a strong breeze, during shaving, smiling, chewing are trigger factors. These factors aggravate the trigger zone. Not only touching the trigger zone, but these factors also play a crucial role in aggravating the condition.

 They often have stabbing kind of pain while biting, chewing, talking etc.

ATYPICAL (TYPE2):

In this type, patients experience a persistently dull or burning sensation in one part of the face. However, episodes of sharp pain can aggravate this type. There are no such trigger zones in this type. Therefore, this feature differentiates from type 1 and type 2 of trigeminal neuralgia. And also, the type of pain differentiates between the two types.

PRETRIGEMINAL NEURALGIA:

The earlier form of trigeminal neuralgia is termed as pretrigeminal neuralgia. Dull continuous pain is present. Typical flashes of pain are the classical feature of this condition. The pain aggravates by thermal stimuli. The exact aetiology is unknown.

INVESTIGATIONS:

MRI (MAGENTIC RESONANCE IMAGING):

Also known as nuclear magnetic imaging, uses a strong magnetic field and radio waves to take detailed scans of the body. That is not seen in x rays. This also detects nerve damage, tumours in trigeminal neuralgia.

REFLEX TEST:

This test is conducted as blink test, masseter muscle test. This is one of the best methods to assess this condition. The trigeminal nerve supplies both motor and sensory supply to the face. Hence, the doctor usually examines trigeminal nerves by this test.

MANAGEMENT:

PHARMACOLOGICAL:

Carbamazepine is an anticonvulsant drug. It is the gold standard in treating this condition. Initial low dose therapy (100-200mg) is usually given to the patients. Titration of the dose is done based on the response. There are certain side effects of this drug such as skin rashes, aplastic anaemia, Steven-Johnson syndrome (serious adverse effect) of carbamazepine.

Also, oxcarbamazepine is equal to carbamazepine. Gabapentin is also a very effective drug for treating this condition. Baclofen is a antispasmodic agent combining with carbamazepine . This minimizes the side effects.

NON PHARMACOLOGICAL METHODS:

SURGICAL:

PERIPHERAL NEURECTOMY:

It is one of the simple, minimally invasive surgical procedures. This method involves surgical removal of trigeminal nerve branches. One of the oldest methods followed in treating this condition. This method also has the danger of inducing trauma to the trigeminal nerve.

PERCUTANEOUS TRIGEMINAL RHIZOTOMY:

Rhizotomy is the sectioning off the roots of the nerve. Hence, this procedure involves sectioning roots of the trigeminal nerve.

PERCUTANOEUS RETROGASSERIAN RHIZOLYSIS:

It is a safe, reliable method. In this, glycerol injection is given under local anaesthesia. It is a rapid, safe, inexpensive method. Recently they have found that this procedure was very effective for patients. And also the prognosis is very good for this procedure.

BALLOON COMPRESSION:

It is a surgical procedure to treat trigeminal neuralgia. In this method, a balloon is inflated into the trigeminal ganglion to relieve pain. Hence, the purpose of this procedure is to compress the trigeminal nerve and also to disrupt the pathway that causes pain.

MICROVASCULAR DECOMPRESSION:

This also known as the Janetta procedure, is the most common surgical method in treating trigeminal neuralgia. It is a neurosurgical procedure, relieves abnormal compression of the trigeminal nerve. It has an 80% of success rate.

LATEST TREATMENT MODALITIES:

BOTOX INJECTION:

One of the latest modalities in treating this condition. Various studies in recent times have found that botulinum toxin injection (type A) is known to reduce pain in trigeminal neuralgia. Recently this was given to a group of patients. Very effective results were obtained.

GAMA KNIFE STEROTACTIC RADIOSURGERY (GKS):

 Is a technique that precisely delivers radio surgical doses (70-90 Gy) to the nerve root and vascular compression. This provides excellent pain relief.

OTHER MODALITY:

CRYOSURGERY:

Liquid nitrogen used to destroy the damaged tissues.  When Liquid nitrogen has a temperature between -346 and -320 F it extremely freezes the tissues. This method is widely used for treating tumours, precancerous lesions, and neuralgia.

CASES REPORTED:

Recently, the most popular Bollywood actor Salman khan had been diagnosed with trigeminal neuralgia. Moreover, the actor often had pain in the face, cheeks, and jaw region. The actor has undergone surgery for this condition. Now, the actor is absolutely fine.

Though many cases have been reporting. This particular disease has suicidal rates due to severe lancinating type of pain. The patients often experience suicidal thoughts.

TIPS TO BE FOLLOWED IN TRIGEMINAL NEURALGIA:

  • Try to follow a neuralgia vegan diet. Hence, this diet controls inflammation, highly associated with chronic pain.
  • A vegan diet is a nutritious diet containing whole grains, nuts, carbohydrates, legumes, fruits, and vegetables. Meats are completely excluded from this diet.
  • Avoid spicy food.
  • Try to avoid food that contains high sugar content, caffeinated drinks may aggravate the condition.
  • Avoid junk and processed food.
  • Avoid gluten rich diet.
  • Consume more of low saturated fat diets such as whole grains, eggs, citrus fruits, berries, and all types of vegetables.
  • To get rid of the pain, some patients keep warm towels on the face and apply pressure on the affected area. Moreover, they think that this makes them get rid of the pain. This method may act as a trigger factor. Therefore, avoid using this method.

CONCLUSION:

To sum up, trigeminal neuralgia is a severe life-threatening condition. Vegan diet therapy should be a part of a good treatment program. Not only medicines but various surgical modalities, vegan diet therapy for these patients also helps to get rid of the condition faster. This may even help the patients to avoid invasive treatment therapies. And also decrease the number of medications they need to take.


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Dr Shalini S.G
I am a dental surgeon. I love travelling and listening to music and a passionate person in research and doing lots of presentation. My area of interest is pathology, diagnosis and forensics.