Trigeminal Neuralgia

Trigeminal Neuralgia

Trigeminal Neuralgia also known as Tic Douloreuv is a disorder that affects the 5th cranial nerve that causes intense paroxysmal pain in one or more trigeminal nerve branches. 

Branches of the Trigeminal Nerve

The trigeminal nerve has 3 divisions i.e

  • The ophthalmic division that supplies the forehead, eyes, nose, meninges, paranasal sinuses and part of the nasal mucosa.
  • The maxillary division supplies the upper jaw, teeth, lip, cheeks, hard palate, maxillary sinus and part of the nasal mucosa.
  • The mandibular division supplies the lower jaw, teeth, lip, buccal mucosa, tongue, part of the external ear and the meninges. More about nerves
Classification of Facial Pain
  • Trigeminal neuralgia, type 1, (TN1): facial pain of spontaneous onset with greater than 50% limited to the duration of an episode of pain (temporary pain).
  • Trigeminal neuralgia, type 2, (TN2): facial pain of spontaneous onset with greater than 50% as a constant pain.
  • Trigeminal neuropathic pain, (TNP): facial pain resulting from unintentional injury to the trigeminal system from facial trauma, oral surgery, ear, nose and throat (ENT) surgery, root injury from posterior fossa or skull base surgery, stroke, etc.
  • Trigeminal deafferentation pain, (TDP): facial pain in a region of trigeminal numbness resulting from intentional injury to the trigeminal system from neurectomy, gangliolysis, rhizotomy, nucleotomy, tractotomy, or other denervating procedures.
  • Symptomatic trigeminal neuralgia, (STN): pain resulting from multiple sclerosis.
  • Post herpetic neuralgia, (PHN): pain resulting from trigeminal Herpes zoster outbreak.
  • Atypical facial pain, (AFP): pain predominantly having a psychological rather than a physiological origin.

Causes of Trigeminal Neuralgia:

  1. Nerve Compression:

    • Explanation:: Compression of the trigeminal nerve by nearby structures, often blood vessels, leading to irritation and pain signals.
    • Example: Blood vessels impinging on the trigeminal nerve, causing compression and neuralgia.

  2. Demyelinating Plaques:

    • Explanation: Damage to the myelin sheath surrounding the trigeminal nerve, disrupting normal nerve function.
    • Example: Demyelination seen in conditions like multiple sclerosis.

  3. Herpes Virus Infection:

    • Explanation: Activation or infection of the trigeminal nerve by the herpes virus, contributing to inflammation and pain.
    • Example: Reactivation of the herpes simplex virus affecting the trigeminal nerve.

  4. Infection of the Teeth and Jaw:

    • Explanation: Infections in the teeth or jaw leading to inflammation and irritation of the trigeminal nerve.
    • Example: Dental infections spreading to the trigeminal nerve branches.

  5. Irritation from Flu-Like Illnesses:

    • Explanation: Inflammatory response due to flu-like illnesses affecting the trigeminal nerve.
    • Example: Increased sensitivity and irritation during or after a viral infection.

  6. Trauma of the Teeth or Jaw:

    • Explanation: Physical injury to the teeth or jaw causing irritation of the trigeminal nerve.
    • Example: Dental trauma resulting in nerve irritation and subsequent neuralgia.

  7. Aneurysm Causing Pressure on the Nerve:

    • Explanation: Enlargement of an artery (aneurysm) putting pressure on the trigeminal nerve.
    • Example: Compression of the nerve by an adjacent aneurysm.

  8. Tumor:

    • Explanation: Presence of a tumor near the trigeminal nerve leading to compression and irritation.
    • Example: Tumor growth impacting the trigeminal nerve.

  9. Arteriosclerotic Changes of an Artery Close to the Nerve:

    • Explanation: Changes in artery walls close to the trigeminal nerve, potentially leading to compression.
    • Example: Arteriosclerosis affecting vessels in proximity to the trigeminal nerve.

Precipitating Factors of Pain:

  1. Light Touch:

    • Explanation: Even gentle touch or breeze on the face triggers severe pain due to the hypersensitivity of the trigeminal nerve.
    • Example: Brushing against the face lightly causing intense pain.

  2. Eating:

    • Explanation: Chewing and the mechanical process of eating can trigger neuralgic pain.
    • Example: Pain occurring during or after meals.

  3. Swallowing:

    • Explanation: The act of swallowing, which involves movement and muscle engagement in the face, can trigger pain.
    • Example: Pain associated with swallowing liquids or food.

  4. Talking:

    • Explanation: Articulating words and facial movements during speech may induce pain.
    • Example: Pain occurring while engaging in conversation.

  5. Sneezing:

    • Explanation: The sudden and forceful nature of sneezing can trigger intense facial pain.
    • Example: Pain experienced during or after sneezing.

  6. Shaving:

    • Explanation: The mechanical action of shaving involving contact with the face can lead to pain.
    • Example: Pain triggered by shaving activities.

  7. Chewing Gum:

    • Explanation: Repetitive jaw movements during gum chewing can aggravate trigeminal neuralgia.
    • Example: Pain associated with chewing gum.

  8. Brushing the Teeth or Washing the Face:

    • Explanation: Activities involving contact with the face, such as brushing teeth or washing, may cause pain.
    • Example: Pain occurring during facial hygiene practices.

  9. Exposure to Wind:

    • Explanation: Sensitivity to environmental factors, such as wind, leading to pain.
    •  Example: Pain triggered by exposure to windy conditions.

Clinical Features of Trigeminal Neuralgia:

 

1. Nature of the Condition:

  • Trigeminal neuralgia is a chronic condition affecting the fifth cranial nerve.

2. Characteristics of Pain:

  • Characterized by unilateral paroxysms of shooting and stabbing pain.
  • Pain typically occurs in the area innervated by the trigeminal nerve branches (ophthalmic, maxillary, mandibular).
  • Most commonly affects the second and third branches.

3. Description of Pain:

  • Pain is often described as a burning, knife-like, or lightning-like shock.
  • Occurs in the lips, upper or lower gums, forehead, or side of the nose.

     

4. Facial Presentation:

  • Presents with severe facial pain.

5. Unilateral Nature:

  • The pain is unilateral, affecting one side of the face.

6. Muscular Involvement:

  • Associated with involuntary contraction of facial muscles.

7. Eye and Mouth Involvement:

  • Can cause sudden closing of the eye or twitching of the mouth.
  • Historically known as tic douloureux, referring to painful facial twitches.

8. Triggers for Pain Episodes:

  • Pain can be spontaneous or initiated by activities such as chewing, talking, or touching the affected side of the face.

9. Impact on Daily Activities:

  • Patients may alter behaviors, such as improper eating, neglect of hygiene, or wearing a cloth over the face.
  • Social withdrawal due to pain-related discomfort.

10 Coping Mechanisms:

  • Excessive sleeping may be adopted as a coping mechanism to deal with pain.

10. Risk of Suicide:

  • There is a risk of suicide due to the disruption of the patient’s lifestyle caused by the intensity of pain.

11. Unpredictable Recurrence:

  • Recurrences are unpredictable, varying in frequency and duration.
  • Episodes can recur for several days, weeks, or months apart.

Pathophysiology of Trigeminal Neuralgia 

  • Classical (idiopathic) form: There is no known cause for the, however, studies point to an underlying vascular pathology as a cause by irritation over the trigeminal (Gasserian) ganglion. Although the cause is not certain, vascular compression and pressure are suggested causes. The disorder occurs more commonly in women and in people with multiple sclerosis (MS) compared with the general population.
  • Symptomatic (secondary) form: There are known common causes affecting the CN, Vascular compression of the trigeminal ganglion

 Differential Diagnosis

  1. Demyelinating (MS) 
  2. CPA tumors
  3. Nasopharyngeal and Paranasal pathology 
  4. Dental Pathology
  5. Herpes zoster
  6. Unstable Angina 

Medical Management of Trigeminal Neuralgia:

Pharmacologic Therapy:

  1. Carbamazepine (Tegretol):

    • Action: Reduces transmission of impulses at nerve terminals, relieving pain.
    • Dosage: Typically prescribed at 100mg.
    • Administration: Given with meals to minimize side effects.

  2. Monitoring and Side Effects:

    • Patients are observed for side effects, including nausea, dizziness, drowsiness, and potential aplastic anemia.
    • Long-term therapy requires monitoring for bone marrow depression.

  3. Alternative Medications:

    • Gabapentin and baclofen are utilized for pain management.
    • If pain control remains inadequate, phenytoin (Dilantin) may be added as adjunctive therapy.

Surgical Management:

  1. Microvascular Decompression:

    • Intracranial approach (craniotomy) to decompress the trigeminal nerve.

  2. Percutaneous Radiofrequency:

    • Produces a thermal lesion on the trigeminal nerve.
    • Immediate pain relief may occur, but side effects may include facial dysesthesia and loss of the corneal reflex.

  3. Gamma Knife Radiosurgery:

    • Utilizes stereotactic magnetic resonance imaging (MRI) to identify the trigeminal nerve.
    • Followed by gamma knife radiosurgery for precise intervention.

  4. Balloon Micro-Compression:

    • Percutaneous procedure disrupting large myelinated fibers in all three branches of the trigeminal nerve.

Nursing Management:

  1. Identification of Triggers:

    • Assist patients in recognizing triggers for facial pain (e.g., hot or cold stimuli, jarring motions).
    • Teach strategies like using cotton pads and room temperature water for facial care.

  2. Oral Hygiene:

    • Instruct patients to rinse their mouths after eating when tooth brushing causes pain.
    • Perform personal hygiene during pain-free intervals.

  3. Dietary Guidance:

    • Advise patients to consume food and fluids at room temperature.
    • Suggest chewing on the unaffected side and opting for soft foods.

  4. Emotional Well-being:

    • Recognize and address anxiety, depression, and insomnia common in chronic pain conditions.
    • Implement appropriate interventions and referrals.

  5. Postoperative Care:

    • Perform neurologic checks to assess facial motor and sensory deficits postoperatively.

  6. Eye Care:

    • Instruct patients not to rub the eye if sensory deficits occur post-surgery.
    • Assess for eye irritation or redness and administer artificial tears if prescribed.

  7. Eating and Swallowing:

    • Observe patients for any difficulty in eating and swallowing foods of different consistencies.

  8. Support Groups:

    • Encourage patients to join support groups for emotional and informational support.

In General,

Trigeminal neuralgia poses a challenge as there is no specific cure. Management focuses on alleviating pain through medications like antiseizure drugs (e.g., carbamazepine, phenytoin, clonazepam) and analgesics during episodes. If conservative approaches prove ineffective, surgical interventions may be considered.

Medical Management:

  1. Drug Therapy:

    • Antiseizure medications, such as carbamazepine, phenytoin, or clonazepam, coupled with analgesics, are administered during pain episodes.

  2. Surgical Options:

    • When conservative measures fail, surgical interventions include:
      • Glycerol injection into trigeminal nerve branches.
      • Suboccipital craniotomy rhizotomy for comprehensive pain relief.
      • Gamma knife radiosurgery.
      • Percutaneous radiofrequency procedures.

Patient Assessment and Education:

  1. Pain Assessment:

    • Thoroughly assess the nature and character of the pain to tailor an effective management plan.

  2. Patient Education:

    • Educate the patient about the condition, its nature, and available treatment options.
    • Emphasize the importance of preventive measures to mitigate the risk of suicide.

Patient Care:

  1. Hygiene and Nutrition:

    • Ensure optimal patient hygiene and nutrition status to support overall well-being.

  2. Psychological Support:

    • Provide psychological support to build patient confidence and aid in coping with the challenging situation.

Diagnostic Investigations:

  1. Ordered Investigations:
    • Ensure that ordered diagnostic investigations, including CT scans, MRIs, and CSF analyses, are completed to guide treatment decisions.
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