What is trigeminal neuralgia?

It is a neurological disorder that causes severe, electric shock-like pain attacks on one side of the face as a result of irritation or pressure on the trigeminal nerve.

What are the causes of trigeminal neuralgia?

The most common cause is pressure from a blood vessel on the nerve as it exits the brainstem, and it may also be associated with multiple sclerosis or rare tumors.

What are the treatment options for trigeminal neuralgia?

Treatments range from anticonvulsant medications, injections or minimally invasive procedures (such as PSR or glycerol injections), to microsurgery to decompress the nerve.

Can trigeminal neuralgia be completely cured?

Symptoms can be largely controlled with appropriate treatment, but attacks may recur over time, and long-term success depends on the type of treatment and the underlying cause.

Trigeminal Neuralgia: Causes and the Latest Treatment Methods- بيمارستان

Trigeminal neuralgia is considered one of the most severe types of facial pain; it is sometimes described as “suicidal pain” due to its intensity. Studies indicate that the incidence rate is approximately 4–13 cases per 100,000 people annually, and it most often occurs in people over 50. The condition is characterized by sudden, severe episodes of pain resembling electric shocks, which may last for a few seconds or minutes. Early diagnosis and appropriate treatment contribute significantly to improving patients’ quality of life.

What is the trigeminal nerve?

Trigeminal neuralgia is one of the most severe types of facial pain, caused by irritation or compression of the fifth cranial nerve (the trigeminal nerve), which originates in the brainstem within the skull. This nerve divides into three main branches:

The ophthalmic branch (V1): transmits sensory input from the forehead, eye, and upper nose.
The superior alveolar branch (V2): transmits sensation from the cheek, upper lip, and roof of the mouth.
The inferior alveolar branch (V3): It transmits sensation from the lower jaw and lower lip, and controls the movement of the masticatory muscles.

When the trigeminal nerve is irritated or compressed, sharp episodes of pain, often described as electric shocks, occur on one side of the face. This disorder is also known as tic douloureux, or “painful facial tic,” due to the involuntary facial twitching triggered by the pain’s intensity. Pain attacks typically last from a few seconds to two minutes and may recur many times a day, with periods of remission between attacks. As the condition progresses, the attacks may become longer and more frequent, significantly impacting quality of life.

Diagram Showing The Areas Innervated By The Trigeminal Nerve

What causes trigeminal neuralgia?

The most common cause of trigeminal neuralgia is believed to be chronic compression of the nerve by a nearby artery or vein as it exits the brainstem, leading to irritation of the nerve fibers and episodes of pain. In some cases, the condition may be associated with damage to the nerve’s protective sheath (myelin), which disrupts the transmission of normal nerve signals and causes pain. This damage may occur in conjunction with multiple sclerosis or, less commonly, due to brain tumors.

In addition, certain other conditions can cause similar facial pain but are not true trigeminal neuralgia, such as tooth infections, sinusitis, shingles, postherpetic neuralgia, or previous facial injuries.

Who is at risk for trigeminal neuralgia?

Trigeminal neuralgia affects 5 out of every 100,000 people and is more common in women than in men; patients are typically middle-aged or older. Some people with multiple sclerosis also develop trigeminal neuralgia.

What are the symptoms of trigeminal neuralgia?

Patients describe trigeminal neuralgia pain as a sharp sensation resembling a prickling or a sudden stabbing; it may feel like a brief electric shock that usually lasts a few seconds, sometimes for a minute or two. An attack can be triggered by simple activities such as talking, chewing, drinking, or even a light touch to specific areas of the face called “trigger zones,” which are often near the nose, lips, eyes, or gums. As a result, some patients avoid eating, speaking, or even washing their faces for fear of triggering the pain. Other daily activities, such as shaving or brushing teeth, may also trigger attacks. The condition is typically characterized by the following features:

In most cases, it affects one side of the face.
It occurs as intermittent episodes that may last for weeks or months, interspersed with periods of remission lasting weeks or even years.
Seizures tend to become more frequent and severe over time, which can significantly impact a patient’s life.

There is another type called atypical trigeminal neuralgia (Atypical TN), which is characterized by chronic, low-intensity pain

accompanied by a burning sensation or numbness, along with episodes of tingling similar to electric shocks. This type differs from the typical form in that it responds less well to conventional treatments and is sometimes difficult to manage.

How is trigeminal neuralgia diagnosed?

When a person first experiences facial pain, they often consult a primary care physician or dentist. If the pain requires further evaluation, a consultation with a neurologist or neurosurgeon may be recommended. The doctor will examine and palpate areas of your face to determine exactly where the pain is occurring and which branches of the trigeminal nerve may be affected.

The underlying causes of trigeminal neuralgia are rarely serious; however, the possibility of a tumor or multiple sclerosis must be ruled out, which is why an MRI scan is usually performed. An MRI scan can detect any blood vessels compressing the trigeminal nerve, and trigeminal neuralgia is diagnosed following a careful evaluation of the patient’s symptoms.

An Mri Scan Showing Trigeminal Nerve Compression

Treatment for Trigeminal Neuralgia in Turkey

There are ways to treat trigeminal neuralgia, and a variety of treatments are available, including medication, surgery, needle procedures, and radiation. The first-line treatment is medication. When medication fails to control the pain or causes intolerable side effects, patients may consult a neurosurgeon to discuss other options.

Use of Medications

Over-the-counter medications such as aspirin and ibuprofen are not effective for trigeminal neuralgia; instead, anticonvulsants and muscle relaxants are prescribed to block pain signals from the nerve. These medications are the first-line treatment for trigeminal neuralgia and are used as long as the pain is controlled and side effects do not interfere with the patient’s activities. At least 80% of patients experience short-term pain relief with medication. For effective pain control, medications must be taken on a regular schedule to maintain a steady blood level.

The treatments listed above are used to manage trigeminal neuralgia, but if the medication begins to lose its effectiveness, your doctor may increase the dose or switch you to a different medication. Side effects may include the following:

Nausea.
Skin rash.
Blood disorders.
Drowsiness and loss of balance.

Therefore, patients are routinely monitored and undergo blood tests to ensure that the medication remains within safe therapeutic levels and that no blood disorders or complications develop. Combination therapy may be necessary to control pain (for example, using Tegretol with Neurontin).

Trigeminal Neuralgia Surgery

Trigeminal neuralgia surgery aims to relieve pressure on the nerve or stop the transmission of pain signals to the brain. These procedures are performed under general anesthesia and may require a one- or two-day hospital stay for observation.

Microvascular decompression (MVD) is one of the most effective procedures. It involves repositioning the blood vessel, compressing the nerve, and placing a small Teflon patch to insulate and protect it. The procedure is performed through a small incision behind the ear in the skull. This surgery provides immediate pain relief for most patients, although symptoms may return over the years in some cases. It rarely causes facial numbness.

An Image Showing Microvascular Decompression (Mvd) As Trigeminal Neuralgia Treatment

Dorsal selective rhizotomy involves cutting the sensory fibers of the nerve where it connects to the brainstem to prevent pain transmission, while preserving the fibers responsible for masticatory muscle movement. This procedure can result in permanent facial numbness, so it is often used for severe or recurrent cases that do not respond to other treatments.

A peripheral nerve can also be removed through a small incision in the face to sever a branch of the affected nerve, such as the supraorbital or infraorbital nerve, depending on the location of the pain. This procedure helps relieve localized pain but causes loss of sensation in the area supplied by the severed nerve.

Radiation Surgery for the Treatment of Trigeminal Neuralgia

Stereotactic radiosurgery is a non-surgical outpatient procedure that uses highly focused radiation beams to destroy specific nerve root fibers causing trigeminal neuralgia. The two main techniques are the Leksell Gamma Knife and linear accelerator systems such as BrainLab Novalis. A head frame or stereotactic face mask is attached to the patient’s head to precisely locate the nerve on an MRI scan and to keep the head completely still during treatment. Highly focused beams of radiation are directed at the trigeminal nerve root, and in the weeks following treatment, a lesion (injury) may develop at the site of radiation.

Pain relief may not occur immediately but gradually over time; as a result, patients continue to take pain medication for some time, and the success of radiosurgery becomes evident when pain medication is reduced or discontinued. After 4 weeks, approximately 50% of patients will experience pain relief without medication or with reduced medication; after 8 weeks, 75% will. Complications include facial numbness and dry eyes, and in about 30% of patients, pain recurs 3 to 5 years after treatment. Repeat radiosurgery can be effective; however, the risk of facial numbness increases.

Outpatient Injection for Trigeminal Neuralgia

Needle procedures are minimally invasive techniques used to treat trigeminal neuralgia, in which the fifth cranial nerve is accessed through the skin using a hollow needle without the need for a large surgical incision or opening of the skull. The goal of these procedures is to selectively damage certain nerve fibers to prevent them from transmitting pain signals to the brain. This often results in varying degrees of facial numbness; this side effect is expected and necessary to achieve long-term pain relief. These procedures are typically performed under local anesthesia with a mild sedative in an outpatient setting, and most patients leave the clinic the same day.

Radiofrequency Root Extraction (PSR)

It is also known as transcutaneous stereotactic radiofrequency neurotomy. The procedure involves inserting a hollow needle with an electrode through the cheek into the nerve area. After the patient is anesthetized, they are temporarily awakened to pass a low electrical current that helps locate the source of pain through a tingling sensation; they are then re-anesthetized, and a precise thermal current is applied to destroy only the fibers causing the pain. This procedure provides immediate pain relief in over 90% of patients, but about 20% may experience a recurrence of pain within 10–15 years. Possible side effects include weakness in the jaw, loss of the corneal reflex, or facial numbness, which are usually temporary, while painful numbness is very rare.

Glycerol injection

The procedure involves inserting a hollow needle into the fluid-filled sac surrounding the trigeminal ganglion, then injecting glycerol to damage the fibers responsible for pain. However, precisely targeting glycerol is difficult, making the results less predictable than with other methods. This intervention provides immediate relief in about 70% of patients, but nearly half may experience a recurrence of pain within 3–4 years. Partial facial numbness is expected, and complications are typically similar to those seen with PSR.

Balloon pressure

In this technique, a catheter is inserted through the cheek into the trigeminal ganglion, and a small balloon is briefly inflated to compress the pain-causing fibers. After several minutes, the balloon is deflated and withdrawn. This procedure provides rapid relief in about 80–90% of patients, but about 20% may experience a recurrence of pain within 2–3 years. Side effects include facial numbness or temporary weakness in the chewing muscles, and rarely, double vision.

In conclusion, trigeminal neuralgia is a physically and psychologically debilitating condition; however, advances in modern medical techniques have made its treatment more effective and safer. From medication to microsurgery, there are multiple options available to manage symptoms and improve patient comfort, and seeking specialized care remains the most important step toward achieving the best outcomes. At the Bimaristan Medical Center in Turkey, patients have access to the latest treatment technologies administered by experts with extensive experience in this field.

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