Trigeminal Neuralgia

Trigeminal neuralgia is one of the most common neuropathic facial conditions, affecting middle aged and older individuals. For some patients medical therapy provides quick and effective relief. For others the problem is more difficult and the depth of diagnostic and therapeutic services offered by a comprehensive pain clinic can spell the difference between success and failure.

Trigeminal neuralgia is a painful condition characterized by severe attacks of lancinating pain in one or more divisions of the trigeminal nerve. It is usually unilateral and even in bilateral cases the individual attacks are usually one sided. There are often sensitive areas that can serve as triggers for an attack. The attacks may be preceded by an aura like appearance of a mild dull aching in the distribution of the coming attack. In milder cases the patient may be pain free between attacks, but as the condition progresses the period between attacks is often filled with a dull aching or throbbing sensation.

While trigeminal neuralgia can begin in the second or third decades of life the incidence is highest among the middle aged and elderly. The condition is characterized by remissions and exacerbations. The first line of treatment is usually anticonvulsant medication with carbamazepine, phenytoin and gabapentin being the most commonly used agents. The goal of medical therapy is to reduce the frequency of attacks. While some patients do quite well with medical therapy, for others progress is limited by lack of efficacy and side effects, most prominently drowsiness.

For patients who fail medical therapy, injection therapy is often effective. The first step is a diagnostic injection to define the anatomical boundaries and to test whether or not ablative therapy will be successful. The most common forms of nerve ablation are radiofrequency energy, cryotherapy or “Gamma Knife”. There are some patients, however, who “fail” their ablative diagnostic block, reporting complete numbness, but no pain relief in the area of their pain. Obviously these are not good candidates for procedures designed to destroy or incapacitate the trigeminal nerve or one of its branches. For these patients electrical stimulation either transcutaneously or via implanted electrodes may be effective.

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