Trigeminal Neuralgia: An Excruciating But Manageable Headache

Trigeminal Neuralgia -leftOne of the worst headaches that a human being can experience is a Trigeminal Neuralgia [TN]. The Trigeminal nerve is one of the 12 nerves which arise from the brain directly. TN is a chronic pain condition that affects this nerve. If you have the condition even a mild stimulus such as brushing your teeth or touching your face can cause a jolt of excruciating pain. The short mild attacks can progress to becoming incapacitated. The good news is that treatment is possible.

There are two types of TN. The one described above is type 1 or the classic type while type 2 can cause constant burning or stabbing pain.

What causes these headaches?

The Trigeminal nerve is the fifth cranial nerve which divides into three branches namely ophthalmic, maxillary and mandibular divisions. All these divisions arise from Gasserion ganglion and supply the whole face. An aneurism of blood vessels [abnormal dilatation of the blood vessel] or a brain tumour at this level can trigger this neuropathic pain. The damage to the protective coating of the nerve exposes the nerve and causes the pain with the trigger.

How do you differentiate from other headaches?

It could be differentiated by its severity and the character. Usually it affects one half of the face which is sharp, strong, shooting and short lived. Some people describe it as an electric shock.

Is it possible to confirm with tests?

No, there is no confirmatory test for this severe neuropathic pain. An MRI may reveal if there is any tumour which can compress at the brain stem level. A typical characteristic history of pain, an exclusive nerve distribution and exclusion of other diseases gives us a clue towards trigeminal neuralgia. Sometimes a simple act like touching, brushing or chewing can trigger pain. Patient might go into a depression very often due to this excruciating pain.

Can this be treated with conventional methods?

Yes, it is always treated with conventional analgesics and anticonvulsants. These are pain killers and medicines that suppress the nerve stimulus. Oral Carbamazepine’s can alleviate the pain significantly. Other drugs like Gabapentin and Pregabalin had been used successfully in selected cases.

Is there any side effect in using these drugs for a longer period?

There are a few immediate side effects like nausea, vomiting and dizziness. Some individuals might get severe allergic reactions. Liver function tests have to be done periodically to adjust the dose. Certain drugs like MAO Inhibitors should not be used along with carbamazepine.

What are the other options available to manage this pain?

Patients who are resistant to the conventional management can be treated with the following interventions:

  1. Surgical microvascular decompression
  2. Stereotactic radio therapy
  3. Percutaneous micro-compression
  4. Percutaneous glycerol rhyzolysis
  5. Radiofrequency ablation of Gasserion ganglion
  6. Ganglion neuromodulation

These interventions either destroy the affected nerves or prevent the nerve from being compressed by the blood vessel.

Which one of these interventions is frequently used?

Radio-frequency ablation of the Gasserion ganglion is used very often these days as there are good evidence on the outcome and lesser complications among the non-surgical interventions. The relapse rates are low and the success rate is very high in radio-frequency ablation. Certain cases might need definite surgical decompression.

Are there any complications of doing radio-frequency ablation?

Yes, there are a few serious complications could occur but it is rare. An inadvertent injury of the blood vessel, infection and corneal keratitis are examples of a few of them.

Is it a day care procedure?

Usually this procedure is done in a day care centre unless the patient has existing systemic problems like diabetes and hypertension. Instructions will be given to the patients in their prior visit as what precautions to be taken. It is better to consult the concerned physician and clear their doubts before giving consent for the procedure.

What are the possible treatment modes that are available at SEESHA?

The evaluation and medical treatment are possible at SEESHA Karunya community hospital and Dr. Sekar Michael can arrange for radiofrequency ablation at Coimbatore Pain clinic or at the hospital if feasible.

Image: Distribution of the maxillary and mandibular nerves, and the submaxillary ganglion. Source/Author: Henry Gray (1918) Anatomy of the Human Body. Plate 778. Access the original Image information here: https://commons.wikimedia.org/wiki/File:Gray778.png

sekar michael Dr. Sekar Michael, underwent post-graduate training in anaesthesiology and pain services at Christian Medical College, Vellore. His passion for chronic pain management led him to specialise in pain services and start a comprehensive interventional pain clinic at Coimbatore.

Besides being active Instructor in Essential Pain Management, he is also the Editor in chief of the Tamil Nadu Journal of Anaesthesia, and has many international and national publications to his credit.

gnanaraj Dr. J. Gnanaraj MS, MCh [Urology], FICS, FARSI, FIAGES is a urologist and laparoscopic surgeon trained at CMC Vellore. He has been appointed as a Professor in the Electronics and Instrumentation Engineering Department of Karunya University and is the Director of Medical Services of the charitable organization SEESHA. He has a special interest in rural surgery and has trained many surgeons in remote rural areas while working in the mission hospitals in rural India. He has helped 21 rural hospitals start minimally invasive surgeries. He has more than 150 publications in national and international journals, most of which are related to modifications necessary for rural surgical practice. He received the Barker Memorial award from the Tropical Doctor for the work regarding surgical camps in rural areas. He is also the recipient of the Innovations award of Emmanuel Hospital Association for health insurance programs in remote areas and the Antia Finseth innovation award for Single incision Gas less laparoscopic surgeries. During the past year, he has been training surgeons in innovative gas less single incision laparoscopic surgeries.
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