Other neuropathic syndromes may affect the trigeminal nerve and mandate different treatments with varied rates of success. Rarely, neuralgias of other cranial nerves can mimic trigeminal neuralgia. It is essential to establish a correct diagnosis and distinguish atypical facial pains from these neuropathic syndromes to avoid unsuccessful therapies.
#1: Trigeminal neuralgia is also known as tic douloureux
#2: it is the most common pain syndrome affecting the face/head
What are the symptoms of Trigeminal Neuralgia?
Classical trigeminal neuralgia is typically associated with "electric-like shocks", lasting only a few seconds but of a debilitating, intense nature. They are usually on one side of the face, most often in the area of the upper cheek down to the level of the jaw, the maxillary (V2) and mandibular (V3) branches of the trigeminal nerve. The ophthalmic division (V1), transmitting sensation from the skin of the forehead and the eye, is less commonly involved. The trigeminal nerve is also known as cranial nerve V. It transmits sensation from the face, eyes and teeth and controls the muscles of mastication (chewing).
Painful attacks may occur spontaneously but are more often associated with a specific stimulus in a "trigger area." Common trigger points are the eyebrow for ophthalmic division pain, the upper lip for maxillary division involvement, and the lower molar teeth for mandibular division pain. Sensory stimuli by touch, cold, wind, talking or chewing can precipate the attacks. Pain-free intervals last for minutes to weeks, but long-term spontaneous remission is rare. The attacks cease during sleep but often occur upon arising in the morning. This constellation of symptoms provides the diagnosis.
#2: touch, cold, wind, talking and chewing can bring on attacks.
What are the causes and risk factors for Trigeminal Neuralgia?
The exact cause of trigeminal neuralgia is uncertain, but there is evidence that vascular compression of a nerve root may be the cause. In younger patients, trigeminal neuralgia can be caused by tumor, aneurysm, or arteriovenous (VESSEL) malformation in the region of cranial nerve V or (more commonly) by multiple sclerosis. These entities must therefore be ruled out.
Most cases of TN are caused by compression of the trigeminal nerve root. Compression by a loop of an artery or vein is thought to account for 80 to 90 percent of cases.
#1: Most cases of Trigeminal neuralgia are caused by compression of the trigeminal nerve usually by an artery or vein.
Diagnosis
Although the diagnosis remains based exclusively on history and symptomatology, Diagnosis is usually made by history and physical exam modern diagnostic techniques, particularly high-resolution magnetic resonance imaging (MRI) , provides valuable new insight into the pathophysiology of these cases with additional implications for therapeutic strategies.
Imaging studies, CT or MRI, with and without contrast enhancement, are normally performed on every patient with trigeminal neuralgia. Often, elongated and tortuous vessels can be seen and tumors of the region need to be excluded as a cause for the syndrome.
#1: Diagnosis is usually made by history and physical exam
#2: CT or MRI may also be ordered if recommended by your doctor.
Treatment
1) Pharmacological
The primary treatment of trigeminal neuralgia is with medicines. Most patients obtain relief, at least initially, within 30 minutes of administration of carbamazepine (Tegretol). This drug does have side effects, mostly bone marrow depression and liver damage, and patients should be monitored by their physician. Some individuals may also respond to phenytoin (Dilantin).
2) Surgical
After medications are not effective, surgical intervention may be necessary. Surgical options include blocking the trigger point with local blocks, neurectomy (surgically removing a portion of the nerve), and block of the nerve branches.
Decisions on which treatment is best for a given patient must be based on the nature of the pain, the health of the patient, imaging findings and consultation with the neurosurgeon.
#1: Your doctor will decide which Medication can be used to relieve symptoms #2: If medications are not effective, surgical intervention may be necessary.
References:
1. Merskey, H, Bogduk, N. Classification of chronic pain. Descriptions of chronic pain syndromes and definitions of pain terms, IASP Press, Seattle 1994, pp. 59-71.
2. Katusic, S, Williams, DB, Beard, CM, et al. Epidemiology and clinical features of idiopathic trigeminal neuralgia and glossopharyngeal neuralgia: similarities and differences, Rochester, Minnesota, 1945-1984. Neuroepidemiology 1991; 10:276.
3. Rozen, TD, Capobianco, DJ, Dalessio, DJ. Cranial neuralgias and atypical facial pain. In: Wolff's Headache and Other Head Pain, Silberstein, SD, Lipton, RB, Dalessio, DJ (eds), Oxford University Press, New York 2001, pp. 509.
4. Childs, AM, Meaney, JF, Ferrie, CD, Holland, PC. Neurovascular compression of the trigeminal and glossopharyngeal nerve: three case reports. Arch Dis Child 2000; 82:311.
5. Fleetwood, IG, Innes, AM, Hansen, SR, Steinberg, GK. Familial trigeminal neuralgia. Case report and review of the literature. J Neurosurg 2001; 95:513.
6. Love, S, Coakham, HB. Trigeminal neuralgia: pathology and pathogenesis. Brain 2001; 124:2347.
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