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Trigeminal Neuralgia

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2006. 5. 5.




What Is Trigeminal Neuralgia?




TN (Trigeminal Neuralgia / tic douloureux) is a disorder of the fifth cranial (trigeminal) nerve that causes episodes of intense, stabbing, electric shock-like pain in the areas of the face where the branches of the nerve are distributed - lips, eyes, nose, scalp, forehead, upper jaw, and lower jaw.  By many, it's called the "suicide disease".  A less common form of the disorder called "Atypical Trigeminal Neuralgia" may cause less intense, constant, dull burning or aching pain, sometimes with occasional electric shock-like stabs.   Both forms of the disorder most often affect one side of the face, but some patients experience pain at different times on both sides.  onset of symptoms occurs most often after age 50, but cases are known in children and even infants. Something as simple and routine as brushing the teeth, putting on makeup or even a slight breeze can trigger an attack, resulting in sheer agony for the  individual.


Trigeminal neuralgia (TN) is not fatal, but it is universally considered to be the most painful affliction known to medical practice.  Initial treatment of TN is usually by means of anti-convulsant drugs, such as Tegretol or  Neurontin.  Some anti-depressant drugs also have significant pain relieving effects.  Should medication be ineffective or if it produces undesirable side effects, neurosurgical procedures are available to relieve pressure on the nerve or to reduce nerve sensitivity.  Some patients report having reduced or relieved pain by means of alternative medical therapies such as acupuncture, chiropractic adjustment, self-hypnosis or meditation.




What are the symptoms of trigeminal neuralgia?


TN is characterized by a sudden, severe, electric shock-like or stabbing pain typically felt on one side of the jaw or cheek. The attacks of pain, which generally last several seconds and may be repeated one after the other, may be triggered by talking, brushing teeth, touching the face, chewing or swallowing. The attacks may come and go throughout the day and last for days, weeks or months at a time, and then disappear for months or years.



What causes trigeminal neuralgia?


The exact cause of TN is not known. However, certain factors - such as physical nerve damage and stress - can trigger the beginning of the painful attacks. Nerve damage may occur as the nerve passes from the openings in the skull to the muscles and tissue of the face. As the damage compresses the nerve, the nerve cells shed a protective and conductive coating known as myelin. Myelin acts as an insulator. Without this insulation, information from nerves would be transmitted inefficiently. This may result in weakness, sensory loss or other neurologic dysfunction. Damage may also be the result of a biochemical change in the nerve tissue itself or an abnormal blood vessel compressing the nerve as it exits from the brain. In almost all cases, an excessive burst of nervous activity from a damaged nerve causes the painful attacks.


In people without TN, blood vessels are usually not in contact with the trigeminal nerve root entry zone. Though pulsation of vessels upon the trigeminal nerve root do not visibly damage the nerve, the irritation from repeated pulsations may lead to changes of nerve function and delivery of abnormal signals to the trigeminal nerve nucleus. Over time, this may cause hyperactivity of the trigeminal nerve nucleus which results in the generation of TN pain.


Psychological stress can be the cause as well as the outcome of TN. In clinical studies, patients have been known to report TN following major stress like divorce, the death of close family members, a job change, or unhealthy family relationships.




How is trigeminal neuralgia treated?


Medications are the first line of treatment for TN and include drugs such as Carbamazepine (Tegretol??), Phenytoin (Dilantin??), Gabapentin (Neurontin??), and Baclofen (Lioresal??). There is also a controled trial using Lamotrignine (Lamcital??). Many of the medications used to treat TN are those originally designed to treat seizures. The anti-seizure agents in these medications suppress excessive nerve tissue activity. If pain becomes more frequent and severe, increased doses of medications are required. This may lead to intolerable side effects and/or inadequate pain control. Since TN is extremely painful, but not life threatening, the goal of therapy is to minimize the dangerous side effects.


If medications do not adequately control TN that progressively worsens, surgical procedures are considered to be the next line of treatment. The surgical procedures considered may include either microvascular decompression (MVD) surgery; alcohol or glycerol injections into the trigeminal nerves; gamma-knife treatment; or some form of nerve injury procedure (rhizotomies). A neurosurgeon can perform MVD surgery if the doctors can successfully determine the cause of the disorder to be compression of an artery on the trigeminal nerve deep inside the skull.


The major disadvantage to surgery is that it requires a neurosurgical operation — with all its complications — to get access to the root of the trigeminal nerve. The success rates of the surgical procedures vary according to the experience of the surgeon or the anesthesiologist.




What do we know about heredity and trigeminal neuralgia?


The exact role of heredity regarding TN remains unclear. However, estimates suggest that roughly 5 percent of TN patients have a history of other family members who have had the disorder. Familial TN has been noted to be more common in women, mostly in women older than 50 years. This has led to speculation that there is a dominant pattern of genetic transfer.




Clinical Research on Trigeminal Neuralgia


Currently, NHGRI is not conducting studies on trigeminal neuralgia.



Additional Resources for Trigeminal Neuralgia




Last Updated: February 2006





Articles And Papers



Fentanyl Effervescent Buccal Tablets in Patients With Chronic Pain


Botulinum Toxin A Relieves Pain of Trigeminal Neuralgia


New York Times:  Practices: A New Use for Botox: Treating Facial Neuralgia


Cymbalta May Aggravate Preexisting Liver Disease


Maternal Use of Anticonvulsants Increases Risk of Craniostenosis in Offspring


Medtronic Patient-Activated Pain Device Wins OK


Botox and Trigeminal Neuralgia


Avinza Interaction With Alcohol May Be Lethal, FDA Warns


Low-Dose Radiation Numbs Lengthy Post-Shingles Pain


Harvard Magazine Cover Story:  The Science of Hurt


Long-Term Use of Antiepileptic Drugs May Lower Bone Mineral Density


Consciously Controlling Brain Activation May Reduce Pain Perception


The Pharmacology of Fentanyl and Its Impact on the Management of Pain


Team Care for Depression Among Elderly Deemed Cost-Effective


Book Review:  "Complementary and Alternative Medicine in the United States"


Reader's Response to the Book Review Entitled "Complementary and Alternative Medicine in the United States"


Author's Response to the Letter Regarding the Book Review  "Complementary and Alternative Medicine in the United States"


Chronic pain: Managing your emotions


Chronic pain: Exercise can bring relief


Painful Choices: Physicians Challenged by Quest to End Suffering
At the debate's core is the love/hate affair with the powerful class of pain medications known as opioids


Support Groups for Chronic Pain


Support Groups for Chronic Pain


Tricyclic antidepressants: Weapons against chronic pain


Use of Herbal Therapies to Relieve Pain: A Review of Efficacy and Adverse Effects


Response by some TNA Medical Advisory Board members to: An open study of botulinum-A toxin treatment of trigeminal neuralgia


Nalbuphine a Safe, Effective Long-Term Therapy for Severe Chronic Pain


Pain patients often suffer in silence


Combining Methadone With Other Long-acting and Short-acting Opioids for Pain Management


Newly Discovered Small Molecules 'Superactivate' Botox


Use records to check up on doctors


Expectations of Pain: I Think, Therefore I Am


Second opinion: 'odd' ways to bring an end to agony


FDA Approvals: Angiomax, Lyrica, Zmax


Diagnosing TN first step toward relief


Doctor finds being the patient is journey of frustration, discovery


The Search for Answers


Repetitive Transcranial Magnetic Stimulation May Be Effective Treatment for Neuropathic Pain


NPR:  Experimental Vaccine Proves Effective Against Shingles


TN featured in Neurological Focus


Recognizing Pain in Alzheimer Patients


USA Today Letter to the Editor


MRI Can Cause Serious Injury in Patients With Implanted Neurostimulators


Try Capsaicin Cream for Painful Conditions


Antiepileptics Have Low Risk of Stevens-Johnson Syndrome


Tiagabine Reduces Neuropathic Pain


Trileptal May Cause Serious Dermatologic Reactions


Compounding Pharmacist, TNA National Conference Speaker


Cymbalta, new drug for Diabetic Neuropathy


Recent Advances in Nonopioid Treatment of Pain


Opioid Therapies for the Management of Pain


How Can the Internet Help Parents of Children With Rare Neurologic Disorders?


Merck Wins Approval for Combined Fosamax Treatment


Osteoporosis and Anticonvulsants


Glaxo Recalls Lamictal Kits in US Due to Wrong Dose


Microvascular decompression for trigeminal neuralgia: comments on a series of 250 cases, including 10 patients with multiple sclerosis


Depression Can Be Managed Effectively


Drug combo packs more relief for chronic nerve pain, scientists say


Percutaneous controlled radiofrequency rhizotomy in the management of patients with trigeminal neuralgia due to multiple sclerosis


Chronic Post-Traumatic Neck and Head Pain


Treatment of herpes zoster and postherpetic neuralgia


Comparison of Percutaneous Trigeminal Ganglion Compression and MVD


Gene Polymorphisms Influence Response to Epilepsy Drugs


Treatment Options for TN - British Medical Journal


Pain in Women's Health: A Multi-Faceted Approach Toward Understanding


The Current State of Pain Management: An Expert Interview With Scott M. Fishman, MD


Valproate Taken During Pregnancy May Increase Risk of Fetal Malformations


TN in patients with multiple sclerosis: lesion localization with magnetic resonance imaging


Gamma Knife Surgery for Trigeminal Neuralgia:  Outcome, Imaging, and Brainstem Correlates


Levetiracetam  (Keppra) for the Treatment of Trigeminal Neuralgia


Injections of Botulinum Toxin Type A Produce Pain Alleviation in Intractable Trigeminal Neuralgia


Anticonvulsant drugs for acute and chronic pain


Gamma Knife Radiosurgery for Trigeminal Neuralgia:  A Study of Predictors of Success, Efficacy, Safety, and Outcome at LSUHSC


MVD for TN in the Elderly:  Safety and Efficacy


Unilateral Black Hair Tongue in Trigeminal Neuralgia


Operative Findings and Outcomes of Microvascular Decompression for Trigeminal Neuralgia in 35 Patients Affected by Multiple Sclerosis


Peripheral Stimulation for Treatment of Trigeminal Post-Herpetic Neuralgia and Trigeminal Post-Traumatic


Diagnosis and Treatment of Patients with Trigeminal Neuralgia


Facial Pain:  Neurological and Non-Neurological


MRI for Radiosurgery


Glycerol Rhizotomy for treating TN related MS


Excerpts from American Academy of Pain Medicine Conference


TN:  The Hidden Hurt


Gabitril Off-Label Use Associated with Risks of New-Onset Seizures


Plenty of pills and potential for abuse:  USA Today


Adjunctive Agents in the Management of Chronic Pain


Treatment of Post-herpetic Neuralgia


Low-dose gabapentin in combination for TN and MS


Quality of Reporting in Evaluations of Surgical Treatment of TN


Gamma Knife Surgery for Trigeminal Neuralgia: 

Outcomes and Prognostic Factors


Short-lasting Unilateral Neuralgiform Headache with Conjunctival Injection and Tearing Syndrome Treated with Microvascular Decompression of the Trigeminal Nerve


Pain in Women's Health: A Multi-Faceted Approach Toward Understanding


Carnitine Deficiency


UCLA Pain Diseases and Disorders:  Trigeminal Neuralgia 


Supplemental Carnitine May Be Helpful in Diabetic Neuropathy


Variants of COMT Gene Influence Pain Sensitivity


County Executive Says Facial Condition Pain Gone


Novel Treatments in the Pipeline for Neuropathic Pain


Listen to the Patient


RV Life Magazine.  Persistence Pays.  Follow-up article.


Dr. Donohue:  Nerve malfunction gives rise to dreadful pain


Post Herpetic Neuralgia

San Antonio Texas Newspaper


Four-Year-Old With TN


Jane Austen - A Life


Actress, Singer and Nurse Kathryn Crosby

to Visit UF as Advocate for Facial Pain Disease


View WebMD: 

"Self-Help:  Popular, but Effective?"


Health and

The Commonest Facial Pain


Health and

Opiods Can Relieve Nerve Pain


Health and

Acupuncture and Chronic Headache


Gamma Knife's Relief Painless

Jacksonville Times-Union, 9-20-04


AARP Article - Rooting Out Pain


 Dr. Donohue:  Nerve Irritation Creates unbearable pain


Dr. Donohue: Medicines can control many facial tics

RV Life Magazine

austinwoman Magazine

 MD News Article

Article Review:   "Gamma Knife Radiosurgery for Trigeminal Neuralgia:"  Shaya M, Jawahar A, Caldito G, Sin A, Willis BK, Nanda A. gamma knife radiosurgery for trigeminal neuralgia: a study of predictors of success, efficacy, safety, and outcome at LSUHSC. Surg Neurol 2004;61:529 -35.  Go to first part of ArticleGo to last part of ArticleReview

Articles From or About the Medical Literature


"Diagnosis and Differential Diagnosis of TN" - Joanna M. Zakrzewska, MD, FDSRCS, FFDRCSI from The Clinical Journal of Pain, 2002.


"Self-Help:  Popular, but Effective?"  The number of self-help books, organizations, and online support groups has mushroomed in recent years.  The range of topics they cover varies -- but their impact is clear.  Article linked to by permission from WebMD.  Written by Dulce Zamora and includes a short interview with TNA Founder and President Emeritus, Claire Patterson. 


"How Can We Evaluate Articles in the Medical Literature?"   This is an effort by the creator of this site to help lay readers think critically about outcome studies and other medical information found on line or in print literature.  Comments are welcome.  We're all learners here.


"Therapeutic Decisions in Facial Pain" is an authorized pre-print of work presented in October 1998 to a meeting of the Congress of Neurological Surgeons at Seattle, Washington.   Dr. John Tew, M.D., and Dr. Jamal Taha, M.D. have reviewed ten years of the medical literature, to assess outcomes from a surgical perspective.  The work was published in the annual edition of Clinical Neurosurgery for 1999.  We are grateful to both authors and to their publisher for permission to present this work for discussion, months in advance of its appearance in print.


"Neurovascular Decompression -- Procedure of Choice?"  This paper was also presented to the October 1998 meeting of CNS. Dr Ronald I. Apfelbaum addresses alternatives in surgical treatment for facial neuralgia.  Like the article above, the work was published in the annual edition of Clinical Neurosurgery for 1999.  We are grateful to the author and to publisher for permission to preprint.


"Choosing Between Treatments for Trigeminal Neuralgia"  is a contribution by Red Lawhern,  writing as the spouse and supporter of a TN patient.  This is a compilation of information from many sources encountered in three years of answering questions from my spouse and other patients.  It is based on research in the medical literature and on the Internet.  Several patients and professionals have read it and prompted re-write some sections.  Some of those who read it have expressed the thought that they wished they had something like it when they were first learning about TN and its treatments. However, the author is  not a health care professional:  any remaining errors are the author's, not the reviewers'.

Please do not attempt to substitute a reading of articles in any source, for consultations with a qualified professional caregiver:  a neurologist, neurosurgeon, craniofacial pain specialist, anesthesiologist, dentist specializing in face pain disorders, or others to whom such caregivers may refer you.  If you find something in this archive that seems to contradict the treatment you are receiving, print it and discuss it with your health care provider.

Abstracts from the Third TNA National Conference held in Pittsburgh, PA on October 26-29, 2002.   Scientific Presentation AbstractsIn October 2000, the third bi-annual Trigeminal Neuralgia conference was hosted at Pittsburgh PA by the Allegheny General Hospital.  The conference featured interactive panel discussions with extensive audience participation. The meetings were supported by a faculty of over 50 medical, dental, and pain treatment professionals from the US and UK and  was attended an audience of 300+ patients, family members, and support group leaders. 



Selected Reports from the Second Annual National Conference, held in Orlando, FL on November 11-15, 1998. 



Updated 1-03-06