What You Should Know About Trigeminal Neuralgia

Ask the Experts

Chuck Mikell, MD
Stony Brook Movement Disorders Center

Trigeminal neuralgia, or tic douloureux, is a devastating facial pain syndrome from which millions of Americans suffer. However, as Chuck Mikell, MD, a neurosurgeon who is an expert in treating this syndrome explains, with proper diagnosis, treatment is available, and there is no reason to live with the pain of trigeminal neuralgia.

Where does the name come from?
The trigeminal nerve supplies the face with sensation; there is one on each side, and each side has three branches. When a person is afflicted with trigeminal neuralgia, usually only one of the three branches of the nerve is affected. Pain can be in the jaw, along the cheek, or on the forehead. There are two types of trigeminal neuralgia that one can experience: type 1 and type 2. Type 1 trigeminal neuralgia (TN1) is characterized by sharp (also referred to as lancinating) pain, which comes in sudden bursts. Type 2 trigeminal neuralgia (TN2) is characterized by constant pain. Characteristically, in TN1, the pain isn’t constant; it comes and goes, and can be set off by touching the skin. It’s not uncommon for a person with TN1 to stop combing their hair or brushing their teeth.

What causes trigeminal neuralgia?
TN1 is caused by a blood vessel pressing on the nerve. For reasons that aren’t completely clear, the pulsations of the blood vessel cause spasms of extreme pain. TN2 is possibly caused by TN1 that has been allowed to persist, untreated, or it could be a sign of a dangerous lesion, like a brain tumor.

Does facial pain after surgery or an injury mean I have trigeminal neuralgia?
The constant, burning pain after injury to the trigeminal nerve is known as a “deafferentation” syndrome. Most often, there is some associated face numbness, and the numb area is in constant, burning pain. This kind of pain doesn’t respond to the usual treatments for trigeminal neuralgia. In fact, these procedures usually make it worse. Deafferentation pain may respond to medicines, stimulating electrodes, or, in rare cases, to a surgery called a nucleus caudalis DREZ (dorsal root entry zone) lesion.

How is trigeminal neuralgia treated?
A neurologist must perform a thorough evaluation before a diagnosis of TN is made and treatment depends on the type of TN. Both TN1 and TN2 are often successfully treated with seizure medicine (carbamazepine and oxcarbazepine are particularly useful). However, many patients’ symptoms are not easily controlled with medicine, or the medicines cause side effects that are difficult for patients to tolerate. In these cases, surgical therapy can be considered.

What are the surgical options?
Surgical therapies for TN fall into two broad categories: surgeries where the pressure is taken off the nerve, and surgeries designed to destroy part of the nerve (lesion procedures). The first kind of surgery is called a microvascular decompression (MVD). In an MVD, surgeons identify the vessel compressing the trigeminal nerve, and put some padding between the vessel and the nerve. Of all treatment options, MVD has the highest success rate, and the lowest long-term recurrence rate, though it is a brain surgery. The lesion procedures are less invasive, but have their own risks, and are associated with some face numbness. One approach is to put a needle into the nerve under x-ray guidance, and then to use a balloon, heat or glycerol to destroy some of the nerve fibers. This is called a rhizotomy. Another option is to target the nerve with very precise, high-dose beams of radiation. This is called radiosurgery. In radiosurgery, there is no open surgery at all. Radiosurgery works very well, but has the risk of leaving you with some face numbness. In fact, all of the lesion procedures come with a risk for some face numbness; however, this is not a typical outcome after MVD. That said, there is no best surgical treatment for TN. Each technique has risks and benefits. A neurologist or neurosurgeon can go over all the options with you, and help you decide what the best approach is for you.

What’s the Stony Brook difference?
As one of just a few neurosurgeons in the tristate area with extra training in functional neurological procedures, I’m often sought out by community neurologists for my expertise in trigeminal neuralgia. And all of the surgical options I mentioned earlier can be performed here at Stony Brook. You’ll find that my colleagues and I at Stony Brook spend a lot of time speaking with you to better understand your personal goals for treatment. We also spend time exploring your fears and anxieties so we can help you come up with a treatment plan that’s right for you.

To learn more or to make an appointment with Dr. Mikell, call (631) 444-1213.

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