Trigeminal Neuralgia Causes and Treatments

BY Dr Smrutirekha Hota

Trigeminal Neuralgia Causes | Why it causes lancinating pain?

Trigeminal neuralgia causes a type of nerve pain that affects the trigeminal nerve, which is responsible for transmitting sensory information from the face to the brain. The exact cause of trigeminal neuralgia is not always clear, but it is thought to be related to compression or irritation of the trigeminal nerve.

In some cases, the compression or irritation of the trigeminal nerve can be caused by a blood vessel pressing against the nerve as it exits the brainstem. Other possible causes include tumors or cysts pressing on the nerve, multiple sclerosis, or injury to the nerve.

The lancinating pain associated with trigeminal neuralgia is believed to be caused by abnormal signals being sent along the nerve fibers because of its demyelination. The pain can be triggered by even mild stimulation of the face, such as brushing teeth or even a light breeze. These triggers cause the nerve to fire abnormally, sending intense pain signals to the brain.

The exact mechanism behind why the pain is lancinating, or sharp and stabbing, is not fully understood. However, it is believed to be related to the way in which the trigeminal nerve transmits pain signals. The trigeminal nerve contains both large and small fibers, and it is thought that the sharp, lancinating pain may be transmitted through the smaller, more finely tuned fibers.

How trigeminal neuralgia progresses?

Trigeminal neuralgia can progress differently for each individual. In some cases, it may start with mild, occasional episodes of pain that gradually become more frequent and severe over time. In other cases, it may begin as severe, frequent episodes of pain right from the start.

In general, trigeminal neuralgia tends to progress in terms of frequency and intensity of pain. The pain episodes may become more frequent, lasting longer and occurring without any apparent trigger. Over time, the pain may become more severe, and the individual may experience a constant, burning pain in addition to the lancinating pain.

As the condition progresses, the pain may also become more difficult to manage with medication. In some cases, individuals may develop tolerance to the medications, requiring higher doses or stronger medications to achieve the same level of pain relief. There is also a risk of medication side effects, which can limit their use in some cases.

In rare cases, trigeminal neuralgia can lead to a progressive loss of sensation in the affected area of the face, which may be permanent. It is important to seek medical attention if you suspect you may have trigeminal neuralgia or if you are experiencing any changes in your symptoms.

How to diagnose trigeminal neuralgia?

Diagnosing trigeminal neuralgia usually involves a thorough medical history and physical examination, along with various tests to help confirm the diagnosis and rule out other conditions that may cause similar symptoms. Here are some common methods used to diagnose trigeminal neuralgia:

Medical history: Your doctor will ask you about your symptoms, such as when they started, how often they occur, and what triggers them. They will also ask about your medical history and any medications you are currently taking.
Physical examination: Your doctor will examine your face, jaw, and neck to look for any signs of swelling, tenderness, or other abnormalities. They may also test your reflexes and muscle strength.
Imaging tests: Imaging tests, such as an MRI or CT scan, may be ordered to look for any structural abnormalities, such as a tumor or blood vessel pressing on the trigeminal nerve.
Nerve conduction studies: These tests measure the electrical activity of the trigeminal nerve to determine if it is functioning properly.
Sensory testing: Sensory testing can help determine the extent of the nerve damage and whether it is affecting other nerves as well.
Trigger testing: Trigger testing involves applying gentle pressure or other stimuli to different areas of the face to see if it triggers a pain episode.

If your doctor suspects that you have trigeminal neuralgia, they may refer you to a pain specialist or a neurologist for further evaluation and treatment.

Know more about Trigeminal Neuralgia in Bengali

Listen to the discussion on trigeminal neuralgia. It is moderated by Dr Gautam Das and panelists were Dr Chinmoy Roy and Dr Debjyoti Dutta.

The discussion was entirely in the Bengali language to make it easy to understand by laypeople.

For more questions contact Daradia directly.

How to differentiate trigeminal neuralgia from other facial or lancinating pain?

Trigeminal neuralgia can be difficult to diagnose, as there are many other conditions that can cause facial pain. Here are some common differential diagnoses of trigeminal neuralgia:

Dental problems: Tooth decay, gum disease, or other dental problems can cause facial pain that may be mistaken for trigeminal neuralgia. A dentist can usually identify dental problems as the cause of the pain.
Temporomandibular joint disorder (TMJ): TMJ disorder can cause pain and tenderness in the jaw joint, which may be mistaken for trigeminal neuralgia. However, TMJ pain is usually more constant and may be associated with clicking or popping sounds when opening the mouth.
Sinus infections: Sinus infections can cause facial pain that may be mistaken for trigeminal neuralgia. However, sinus pain is usually more diffuse and may be accompanied by other symptoms, such as congestion, headache, or fever.
Cluster headaches: Cluster headaches can cause severe pain on one side of the head that may be mistaken for trigeminal neuralgia. However, cluster headaches usually occur in cycles and are often accompanied by other symptoms, such as eye watering, nasal congestion, or facial sweating.
Glossopharyngeal neuralgia: Glossopharyngeal neuralgia is a similar condition that affects the glossopharyngeal nerve, which provides sensation to the throat and tongue. Symptoms include severe, lancinating pain in the back of the throat and tongue, and can be mistaken for trigeminal neuralgia.

If you are experiencing facial pain, it is important to seek medical attention to determine the underlying cause and receive appropriate treatment. Your doctor may order tests or refer you to a specialist, such as a neurologist or pain management specialist, for further evaluation.

Trigeminal Neuralgia Causes

Primary or idiopathic trigeminal neuralgia may be caused due to contact between any aberrant blood vessels and the trigeminal nerve where the former puts pressure and rubs the nerve causing demyelination (as the skin gets peeled due to repeated scratching similarly, the covering of the nerve gets damaged by pulsating artery friction). Patient experiences pain due to the damaged nerve. This is a hypothesis which is not been proved yet.

Among other causes, aging, multiple sclerosis, demyelinating disorders, compressive tumors, stroke, facial trauma, surgical injuries may be responsible for trigeminal neuralgia.

What other investigations are done in trigeminal neuralgia patients?

There are several investigations that may be done in patients with trigeminal neuralgia to help confirm the diagnosis and rule out other conditions that may cause similar symptoms. These investigations may include:
Magnetic Resonance Imaging (MRI): MRI is a non-invasive imaging test that uses powerful magnets and radio waves to produce detailed images of the brain and surrounding tissues. An MRI can help identify any structural abnormalities, such as a blood vessel or tumor, that may be causing compression or damage to the trigeminal nerve.
Computed Tomography (CT) Scan: A CT scan is a non-invasive imaging test that uses X-rays and a computer to produce detailed images of the brain and surrounding tissues. A CT scan may be used to rule out other conditions that may be causing facial pain.
Electromyography (EMG): Electromyography is a test that measures the electrical activity of muscles and nerves. EMG may be used to evaluate the function of the trigeminal nerve and determine if it is functioning properly.
Sensory Testing: Sensory testing can help determine the extent of the nerve damage and whether it is affecting other nerves as well. This can be done using a variety of methods, such as a cotton swab or pinprick test, to evaluate the sensation in different parts of the face.
Blood Tests: Blood tests may be done to rule out underlying medical conditions, such as infections or autoimmune disorders, that may be causing facial pain.
Your doctor may recommend one or more of these investigations based on your symptoms and medical history. The results of these investigations can help guide treatment decisions and may also help identify any underlying medical conditions that need to be treated.

How to start treatment?

Like any other chronic disease, we can not cure it entirely. Still, we can control the severity of the disease. In this condition, the strongest pain killers also do not work as the source of pain is the nerve; hence, the drugs are used for neuropathic pain control.

What is the treatment approach to trigeminal neuralgia patients?

Medications
Local injection
Surgery

Medication commonly used is carbamazepine

Carbamazepine is an anti-epileptic drug, but it is effectively used for trigeminal neuralgia patients. It usually alleviates the pain effectively. However, it has to be started at a low dose. In addition, it causes side effects like sleepiness, gastrointestinal disturbances, head reeling, low sodium in the body leading to mental disorders commonly in elderly patients.
It is started at low doses of 100 mg thrice daily, increasing gradually and to be continued for a more extended period without any time limit, and carbamazepine doses to be escalated gradually till the desired effect is achieved.
Before starting carbamazepine, routine blood tests are done. In some patients, blood count may reduce after starting the drug. In addition, Steven Johnson syndrome is an uncommon but potentially severe condition with carbamazepine where a stoppage of the drug is warranted.
In patients intolerant to carbamazepine, we can give oxcarbazepine due to fewer side effects.
Baclofen is given in some cases.
Pregabalin and Gabapentin can be tried in a few cases.

What if the drugs are not effective in trigeminal neuralgia?

Suppose the medical treatment is ineffective in controlling the pain severity or patients are intolerant to the drugs due to their side effects. In that case, pain intervention is to be performed.

Radio-frequency ablation of Gasserian ganglion is performed to block the pain pathway. It is a minimally invasive procedure where the needle enters the brain through the face, and heat energy is delivered. It is different from the common injection, but it doesn’t require any brain surgery.

How radiofrequency ablation of Gasserian ganglion is done?

An OT setup is needed for this procedure, which is done under an X-ray machine.
No general anesthesia is required, usually done under local anaesthesia.
Under fluoroscopy guidance, the Gasserian ganglion is identified, cross-checked via an electrical stimulation test.
After radiofrequency ablation of the ganglion, slight numbness in the mouth may remain, but it gradually disappears with time.

What are radiofrequency ablation’s short-term and long-term side effects?

Immediately after the procedure, needle prick site pain can be felt, which lasts for approximately 2 to 3 days.

Sometimes swelling of the face can last for 1-2 days as the face is highly vascular.

Numbness of the face for 7 to 10 days may be experienced by some patients after the procedure.

Complications – vocal cord paralysis can occur, but it is not permanent. It is seen in 1 in 500 patients due to the needle injury to the surrounding nerves of Gasserian ganglion.

Is there any life risk?

Before starting the procedure, coagulation parameters are to be checked to prevent bleeding complications, and prophylactic antibiotics are to be given to prevent infection, especially in diabetic patients with adequate blood sugar control.

It is not done when there are local infections, sepsis, coagulopathy, increased intracranial pressure, major psychopathology.

Under image guidance and nerve stimulation test, the complications rates are minimal if the needle is placed correctly with precaution.

Is there any other procedure besides radiofrequency ablation for trigeminal neuralgia?

In the percutaneous balloon micro compression method, a big needle of 14G, 10 cm, then a caterer called a Fogarty catheter inserted, so the severity of pain and bleeding risk is more. We need general anaesthesia to perform it. But no extra advantages in terms of duration of pain-free period.
Surgical microvascular decompression-Surgery involves making a hole in the skull (craniotomy) and exposing the nerve at the base of the brain to insert a tiny sponge between the compressing vessel and the nerve. Microvascular decompression recovery time may span between two and four weeks, with gradual progress made along the way. It involves risks of, Infection. Hearing loss, facial numbness, and/or facial weakness (usually temporary, rarely permanent) Spinal fluid leak. Recurrence may occur in 18–30% of patients, mainly within 2 years of surgery.
Percutaneous Glycerol rhyzolysis injection is an old technique, but the pain relief is very short-lasting. Here we put a needle filled with a small amount of glycerol into the ganglion from where the trigeminal nerve divide and comes out of the skull. This procedure blocks pain signals in the trigeminal nerve and helps to reduce pain.
Cryoablation of superficial branches of trigeminal nerve and Gasserian ganglion is very effective for trigeminal neuralgia. In this method, a needle is passed similarly as of radiofrequency ablation, then the nerve is frozen at -80⁰C. Cryoablation has the advantage of less painful condition and without any motor paralysis.
Botox (Botulinum toxins) injection in the face is one of the effective methods for Trigeminal neuralgia. Disadvantage of this procedure is that it has to be repeated every 3-6 months and it becomes very costly in long run.
Stereotactic microvascular decompression is only done when the patient is unfit for either intervention or surgery. Gamma Knife treatment for trigeminal neuralgia stops pain in most patients, usually within 10 days.

How effective is stereotactic radiation therapy or Gamma knife?

The Gamma Knife is a device that delivers precise, controlled beams of radiation that target nerves inside the skull, including the brain and associated nerves. Pain relief in gamma knife is not immediate, and the failure rate is high. However, a needle prick is not needed for this procedure. Side effects are there, and that include tingling or numbness in the face

Take home message

Best pain relief is obtained by RFA for an approximate period of 5- 10 years.
Glycerol injection effectiveness is about 5 to 6 months; hence repeated injections are required.
Young patients with trigeminal neuralgia are preferred surgery to elderly patients, but before surgery, radio-frequency ablation should be tried as the pain relief is more consistent with it.
Surgery is not a permanent cure method as recurrences are common even after surgery, and surgery has more side effects.

What is the Trigeminal Neuralgia treatment at home?

While medical treatment is necessary to effectively manage trigeminal neuralgia, there are some home remedies that may help alleviate symptoms and improve quality of life. Here are some home remedies that may be helpful for trigeminal neuralgia:

Cold compress: Applying a cold compress to the affected area may help reduce pain and inflammation. Wrap an ice pack in a towel and apply it to the affected side of the face for 15-20 minutes at a time.
Warm compress: A warm compress can also help reduce pain and muscle tension. Soak a washcloth in warm water and apply it to the affected area for 15-20 minutes at a time.
Relaxation techniques: Stress and anxiety can trigger trigeminal neuralgia symptoms. Relaxation techniques, such as deep breathing, meditation, and yoga, may help reduce stress and improve symptoms.
Avoiding triggers: Certain triggers, such as hot or cold temperatures, wind, and stress, can trigger trigeminal neuralgia symptoms. Avoiding these triggers may help reduce the frequency and severity of symptoms.
Dietary changes: Certain foods, such as those that are high in sugar or caffeine, may trigger symptoms. Maintaining a healthy diet and avoiding trigger foods may help reduce symptoms.

It’s important to note that these home remedies may not be effective for everyone, and they should not be used as a substitute for medical treatment. If you are experiencing symptoms of trigeminal neuralgia, it’s important to seek medical attention to determine the underlying cause and receive appropriate treatment.

Is there any relation between bananas and trigeminal neuralgia?

There is no clear evidence to suggest a direct relationship between bananas and trigeminal neuralgia. However, some people with trigeminal neuralgia have reported that consuming certain foods or drinks can trigger their symptoms. These trigger foods and drinks can vary from person to person and may include things like chocolate, caffeine, alcohol, and spicy foods.

In some cases, foods that are high in potassium, such as bananas, may also trigger symptoms in people with trigeminal neuralgia. This is because high potassium levels can lead to nerve overexcitement, which may exacerbate pain symptoms in some people.

If you have trigeminal neuralgia, it may be helpful to keep a food diary to track your symptoms and identify any trigger foods or drinks. However, it’s important to note that dietary changes alone are unlikely to provide complete relief from trigeminal neuralgia symptoms. Medical treatment, such as medication or surgery, is usually necessary to effectively manage this condition.

What is the best hospital for trigeminal neuralgia treatment in India?

At Daradia: The Pain clinic, Kolkata, India, all kinds of refractory trigeminal neuralgia non-surgical treatment options are available. Contact Daradia for new trigeminal neuralgia treatments in 2023. All kinds of interventional pain management procedures are done here including the latest treatment of trigeminal neuralgia treatment like Cryoablation for trigeminal neuralgia which is done only here in India. If asked what is the latest treatment of trigeminal neuralgia, cryoablation of Gasserian ganglion and botox injection are very effective latest treatments that are very safe also.