Treatment of Trigeminal Neuralgia
What is trigeminal neuralgia?
Trigeminal neuralgia (tri-jem´-in-al noo-ral´-ja), or tic doloureux (tick- dol´-a-roo) is a painful condition that affects the trigeminal nerve in the face. The nerve has three branches. The two in the lower face are most often involved.
Upper 1st Branch - Ophthalmic
Eye, eyebrow, forehead and frontal portion of the scalp
Middle - 2nd Branch - Maxillary
Upper lip, upper teeth, upper gum, cheek, lower eyelid and side of nose
Lower - 3rd Branch - Mandibular
Lower lip, lower teeth, lower gum and side of the tongue. Also covers a narrow area that extends from the lower jaw in front of the ear to the side of the head
What causes trigeminal neuralgia?
No one really knows the cause. Some think that a blood vessel or tumor pressing on the nerve might be the trigger. Other causes could be trauma to the trigeminal nerve or perhaps an infection of the jaw or teeth.
How can trigeminal neuralgia be treated?
There are three treatments:
- Treatment performed through the skin (percutaneous therapy)
- Surgery under general anesthesia1
The medicines most commonly used to treat trigeminal neuralgia are Tegretol, Dilantin, Neurontin, and Baclofen. Tegretol, Dilantin and Neurontin are also used to treat seizures. We know they relieve facial pain, though we don't understand exactly how they work.
Benefits: Taking medicine is the easiest treatment. You do not have to be hospitalized and the dose and kind of medicine can be adjusted to your level of pain. Patients work with their doctor to increase or decrease the dose of medication. Tegretol and Dilantin have been used for several decades. They are usually very well tolerated and can be taken for a lifetime.
Risks: Some patients cannot tolerate these drugs, and in some cases the drugs lose their ability to relieve pain.
Patient responsibilities: Take your medicine as directed by your doctor. Work closely with your doctor to adjust the dose. Be sure to tell your doctor if the medicine fails to work.
There are several types of percutaneous2 therapies.
- Percutaneous radiofrequency rhizotomy: This treatment uses a radiofrequency (RF) electrode3 placed through the skin of the cheek. RF heating at the tip of this electrode can then destroy selected nerve fibers (rhizotomy). After rhizotomy, you will be asked to sit in a wheelchair, bent over at the waist, for about 1 hour.
- Glycerol injection: This treatment involves similar placement of a needle. A small amount of glycerol4 is injected into the space around the nerve fibers.
- Alcohol injection: This older treatment is not used often. It involves the injection of small amounts of alcohol into the nerve endings.
Benefits: While this type of therapy is invasive5, you do not need general anesthesia. The hospital stay is usually overnight.
Risks: With any invasive treatment there is a small risk of infection. In a few cases, pain is not relieved. You will have numbness in part of your face. If this affects the cornea of the eye (from an ophthalmic branch block), you will have to protect your eye, since your ability to feel in that eye will be impaired. There is a chance that the nerve may grow back and the pain may reoccur.
Procedure preparation: To prepare for this therapy you will be seen by our Pre-admission Testing Department (PAT). A health care provider will tell you when to arrive for the therapy, and what you need to do the night before and the morning of the procedure.
How/where performed: These therapies are performed either in the Radiology Department or in the operating room. They are set up as minor operative procedures. You will be given a sedative during the procedure to help you to stay relaxed.
Preparing for discharge: You may be able to go home the day of surgery, or by the following morning.
- Follow the instructions given by Pre-admission Testing. They will tell you what time to arrive, what medicines you may take, and other special instructions.
- Before the therapy you should arrange for the following:
- A ride to and from the hospital
- Plan for meals that are easy to prepare and eat (soft foods will be best at first)
- Have someone nearby who will check on you often or be with you daily to help with minor needs until you are independent.
The following are surgeries that are done:
- Microvascular decompression: This surgery is performed by going into the skull and moving the blood vessel away from the trigeminal nerve. A small pad is then placed between the vessel and the nerve to keep them apart.
- Open retrogasserian rhizotomy6: The skull is opened and part of the sensory root7 of the trigeminal nerve is divided.
Benefits: These surgeries allow the surgeon to look at the nerve and most directly treat the condition.
Risks: The risks associated with these surgeries include a small chance of infection or numbness. Although rare, stroke or death may occur. The facial pain can come back even after these surgeries.
Surgery preparation: Pre-admission Testing will perform blood and medical tests to ensure your health during the surgery. They will tell you when to arrive and where to go for surgery.
How/where performed: The surgery is performed in the operating room. Afterwards, all patients go to the recovery room until they are ready to go to the inpatient unit. Some patients may spend the night in our special care unit. This will allow the nurses and doctors to watch the patient closely and check them often.
Preparing for discharge:
- Most patients can go home 2 or 3 days after surgery. Get plenty of rest and gradually increase your activity. You should plan on 4 to 6 weeks to recover.
- Nutrition and fluids are important, but you may not feel like preparing meals right away. Before surgery, cook some meals that are easy to chew, and freeze them for use after you go home.
- Arrange to have someone check on you and help you until you are independent.
When should I call my doctor?
Call your doctor if...
- Your pain gets worse and can not be relieved
- Nausea and vomiting occur
- An increase in redness or swelling at the site
- Fever of 101F or above
- Drainage occurs
When will I see my doctor following treatment?
We will schedule an appointment to see you 4 to 6 weeks after you leave the hospital. Feel free to call us if you have questions or concerns before that time.
Neurosurgery Nurses Office .............. (603) 650-8304
Neurosurgery Clinic ........................... (603) 650-5109
Dr. Roberts .......................................... (603) 650-8736
Resident On Call ............................... (603) 650-5000*
Nurses Station ..................................... (603) 650-7305
* This is the main number to the hospital. Ask the operator to page the Resident On Call.
Dartmouth-Hitchcock Medical Center
Matthew Fuller Health Sciences Library
Level 5 in Rotunda
Trigeminal Neuralgia Association
P.O. Box 340
Barnegat Light, New Jersey 08006
2 Percutaneous: Through the skin.
3 Radiofrequency electrode: A special probe that uses a radiofrequency (RF) current to destroy selected nerve fibers.
4 Glycerol: An alcohol preparation used for injection to treat trigeminal neuralgia.
5 Invasive: In this situation it refers to the procedures that involve going through the skin.
6 Rhizotomy: Surgical division of nerve roots.
7 Sensory Root: The portion of the nerve root that is responsible for sensation, such as pain or numbness.
Page reviewed on: Apr 06, 2005