Where is trigeminal neuralgia

The trigeminal nerve is one of 12 pairs of nerves that are attached to the brain. The nerve has three branches that conduct sensations from the upper, middle, and lower portions of the face, as well as the oral cavity, to the brain. The ophthalmic, or upper, branch supplies sensation to most of the scalp, forehead, and front of the head. The maxillary, or middle, branch stimulates the cheek, upper jaw, top lip, teeth and gums, and to the side of the nose. The mandibular, or lower, branch supplies nerves to the lower jaw, teeth and gums, and bottom lip.

More than one nerve branch can be affected by the disorder. Rarely, both sides of the face may be affected at different times in an individual, or even more rarely at the same time called bilateral TN. TN is associated with a variety of conditions.

TN can be caused by a blood vessel pressing on the trigeminal nerve as it exits the brain stem. This compression causes the wearing away or damage to the protective coating around the nerve the myelin sheath. Rarely, symptoms of TN may be caused by nerve compression from a tumor, or a tangle of arteries and veins called an arteriovenous malformation. Injury to the trigeminal nerve perhaps the result of sinus surgery, oral surgery, stroke, or facial trauma may also produce neuropathic facial pain.

Pain varies, depending on the type of TN, and may range from sudden, severe, and stabbing to a more constant, aching, burning sensation. The intense flashes of pain can be triggered by vibration or contact with the cheek such as when shaving, washing the face, or applying makeup , brushing teeth, eating, drinking, talking, or being exposed to the wind. The pain may affect a small area of the face or may spread. Bouts of pain rarely occur at night, when the affected individual is sleeping.

TN is typified by attacks that stop for a period of time and then return, but the condition can be progressive. The attacks often worsen over time, with fewer and shorter pain-free periods before they recur.

Eventually, the pain-free intervals disappear and medication to control the pain becomes less effective. The disorder is not fatal, but can be debilitating. Due to the intensity of the pain, some individuals may avoid daily activities or social contacts because they fear an impending attack.

Trigeminal neuralgia occurs most often in people over age 50, although it can occur at any age, including infancy. In the cases of dental work, it is more likely that the disorder was already developing and then caused the initial symptoms to be triggered. Pain often is first experienced along the upper or lower jaw, so many patients assume they have a dental abscess. Some patients see their dentists and actually have a root canal performed, which inevitably brings no relief.

When the pain persists, patients realize the problem is not dental-related. TN1 is characterized by intensely sharp, throbbing, sporadic, burning or shock-like pain around the eyes, lips, nose, jaw, forehead and scalp. TN1 can get worse resulting in more pain spells that last longer. TN2 pain often is present as a constant, burning, aching and may also have stabbing less intense than TN1.

TN tends to run in cycles. Patients often suffer long stretches of frequent attacks, followed by weeks, months or even years of little or no pain. The usual pattern, however, is for the attacks to intensify over time with shorter pain-free periods. Some patients suffer less than one attack a day, while others experience a dozen or more every hour. The pain typically begins with a sensation of electrical shocks that culminates in an excruciating stabbing pain within less than 20 seconds.

The pain often leaves patients with uncontrollable facial twitching , which is why the disorder is also known as tic douloureux. Pain can be focused in one spot or it can spread throughout the face. Typically, it is only on one side of the face; however, in rare occasions and sometimes when associated with multiple sclerosis, patients may feel pain in both sides of their face.

Pain areas include the cheeks, jaw, teeth, gums, lips, eyes and forehead. The symptoms of several pain disorders are similar to those of trigeminal neuralgia. TNP results from an injury or damage to the trigeminal nerve. TNP pain is generally described as being constant, dull and burning. Attacks of sharp pain can also occur, commonly triggered by touch. Additional mimickers include:. TN can be very difficult to diagnose, because there are no specific diagnostic tests and symptoms are very similar to other facial pain disorders.

Therefore, it is important to seek medical care when feeling unusual, sharp pain around the eyes, lips, nose, jaw, forehead and scalp, especially if you have not had dental or other facial surgery recently. The patient should begin by addressing the problem with their primary care physician.

They may refer the patient to a specialist later. A high-resolution, thin-slice or three-dimensional MRI can reveal if there is compression caused by a blood vessel.

Newer scanning techniques can show if a vessel is pressing on the nerve and may even show the degree of compression. Most patients start out on low doses, gradually increasing the dose under clinical supervision until they achieve the best pain relief with the least amount of side effects. Nerve blocks are injections with a steroid medication or another agent made at various parts of the nerve to reduce pain.

They may provide temporary pain relief for people with trigeminal neuralgia. Multiple injections are usually needed to achieve the desired relief, and the effects may have different durations for different people. If medication no longer controls your trigeminal neuralgia pain despite the increased dosage, or if the side effects are intolerable, there are several surgical procedures to consider.

It helps to learn about these options before you are in urgent need of relief so you and your doctor have time to evaluate them. Your overall health, age, pain level and the availability of the procedure will all factor in to this decision.

Most people with trigeminal neuralgia are candidates for any of the surgical treatment options — your doctor can help you decide which ones and in what order you should consider them. The surgery for trigeminal neuralgia is delicate and precise since the involved area is very small. Look for experienced neurosurgeons who see and treat a large number of people with trigeminal neuralgia. There are several kinds of rhizotomies for trigeminal neuralgia, which are all outpatient procedures performed under general anesthesia in the operating room.

The surgeon inserts a long needle through the cheek on the affected side of the face and uses an electrical current heat or a chemical glycerin or glycerol to deaden the pain fibers of the trigeminal nerve. For those undergoing trigeminal neuralgia rhizotomy for the first time, the chemical approach is typically recommended. Those who have the procedure repeated often benefit from both the chemical and the heat treatment delivered in the same session.

The procedure takes about 30 minutes and most patients go home several hours later with less to no pain. Out of the three surgical options, rhizotomy offers the most immediate relief from trigeminal neuralgia pain. You may experience some swelling or bruising of the cheek. Your doctor will prescribe pain medications and, if necessary, give you a plan to gradually discontinue your medications. Rhizotomy is a recommended surgical treatment for patients with trigeminal neuralgia resulting from multiple sclerosis MS.

It is minimally invasive and can be safely repeated, since the pain is more likely to come back due to the progression of MS. It is suitable for people in good health who can tolerate surgery and general anesthesia, and whose lifestyles can accommodate a recovery period of four to six weeks.

The goal of the MVD surgery is to separate the blood vessel from the trigeminal nerve by placing a cushion made of Teflon between them. The surgeon makes an incision behind the ear and removes a small piece of the skull to gain access to the trigeminal nerve and surrounding blood vessels. Then, the surgeon places a cushion around the blood vessel so it no longer compresses or rubs against the nerve.

The surgery takes two to three hours, and patients can expect to spend up to a couple of days in the hospital for recovery and observation. The pain relief with MVD is quick but not immediate. The risks of this surgery include cerebral spinal fluid leak, hearing loss if the hearing nerve is affected and facial numbness that may persist in some cases. The patient is woken from sedation to identify whether they can feel the electrical pulses and put back under while the electrodes heat up and destroy the nerve.

The doctor makes a small hole in the skull and severs the nerve. As the base of the nerve is severed, the patient will have permanent facial numbness.

Sometimes the doctor rubs the nerve instead of severing it. A high dose of radiation is aimed at the root of the trigeminal nerve, gradually resulting in nerve damage and pain reduction. The patient will experience slowly improving pain relief over several weeks. Initial benefits may take several weeks to appear.

There are no guidelines for preventing the development of trigeminal neuralgia. However, the following steps may help prevent attacks once diagnosed:. Trigeminal neuralgia can be debilitating, but managing the symptoms can drastically improve the quality of life. Demyelination is damage to the myelin layer, or the protective coating of nerve cells. This can lead to neurological problems, including slow reflexes.

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