QUESTION: My husband has been diagnosed and is being treated for Trigeminal neuralgia (TN). We read about this condition and our guess is that the information we found could be updated, hence my contacting you.
My husband has seen a neurologist who has prescribed Lyrica, which he’s been on for six weeks. It’s a “lonely” condition because no-one understands the levels of pain nor the side effects of it.
He is looking at alternative treatment such as reflexology, acupuncture and possibly homeopathy. He’s also been in contact with someone who suffered from this condition and recovered. This person waited patiently for the condition to pass (eight months) as there is “no cure” for it.
Are you able to offer any further information, guidance, advice or referral on the topic?
ANSWER: The condition you describe is renowned as one of the most devastating pain conditions in medicine, with challenging aspects in its treatment. I can only imagine the impact it has on your marriage and family life, as well as his own personal life.
To many people these are just medical terms; to the victims it seems close to horrific.
In approaching treatment of any medical illness it is essential to understand the disease process. Managing it can then be accurate and guided and should not be the pitfall so many clinicians fall into of the “shotgun approach” .
The postulated theories regarding Trigeminal neuralgia (TN) are logical but complex. Trigeminal neuralgia is a common and potentially disabling pain syndrome, the exact pathophysiology of which remains obscure.
Causes of the pain are divided into central, peripheral or both. The trigeminal nerve (cranial nerve V) has a primary function of facial sensation – with three distinct divisions supplying the landmarks of the face or simply put: the upper (forehead), middle (cheeks and nose and lower (lips and chin) .
No structural lesion is found to be the cause in most cases and many investigators agree that vascular compression, typically venous or arterial loops at the trigeminal nerve entry into the pons (brainstem), is critical to the mechanism that causes the disease.
Typical signs and symptoms
Ice-pick stabbing, unilateral facial pain. In most patients a piercing knife-like pain is felt shooting from the corner of the mouth to the angle of the jaw. In others there are shocks of pain from the upper lip or canine teeth to the eye and eyebrow, sparing the eye area. The eye is rarely involved in cases and the condition affects the right side of the face five times more frequently than the left.
Pain is severe, sudden and begins with jolts in an affected area progressing within seconds to excruciating discomfort deep in the face, resulting in facial grimacing or tics in an attempt to alter the wave of pain – “tic douloureux”. Patients can be left with a burning ache for hours and even days. Frequency may vary from less than one a day to hundreds a day.
Complications
Adverse effects and toxicity of overused drugs like anticonvulsive agents. Sensitivity and variable efficacy over several years of these meds often leads to the use of a second drug.
Surgery in the form of percutaneous neurosurgical procedures and microvascular decompression procedures pose risks of long-term complications.
Perioperative risks are often overlooked. Delayed onset of relief post surgery and a limited period of relief before considering more surgery is a reality. Permanent sensory loss over a portion of the face or mouth can occur. Jaw weakness and corneal anaesthesia may lead to corneal ulcers. After any invasive treatments, reactivation of a herpes simplex infection is not uncommon.
Anaesthesia dolorosa, an intractable facial dysesthesia, can be disabling and even worse than the original trigeminal neuralgia, and sometimes follows surgery.
Treatment modalities
The approach to the management of this condition must be tailored individually. Comorbidity , gender and age play a role in treatment choices. Major categories are pharmacologic therapy, percutaneous procedures, surgery, and radiation therapy. Medications used are predominantly anticonvulsive drugs of which Carbamazepine is used with great initial effect – often followed by Gabapentin or Amitriptiline in various combinations. The use of antidepressants has become popular in view of the comorbid depression and irritability that may arise from this chronic pain syndrome.
Outpatient treatment is indicated in most cases due to the chronicity of condition, unless neurosurgical intervention is required. Transcranial magnetic stimulation appears promising, but results are to be confirmed in good studies. Adjunct therapies involving electrical stimulation and hypnotherapy have been mentioned in anecdotal reports.
Please don’t give up – the road is long with a many a winding turn. I wish him a speedy recovery.
Triggers of Trigeminal neuralgia
* Chewing.
* Talking.
* Yawning, brushing teeth.
* Shaving.
* Drinking hot or cold beverages.
* Breeze on the skin of the face.
* Touching the affected areas on the face.
* Dr Darren Green, a trusted figure in the field of media medicine, is a University of Stellenbosch graduate who adds innovative spark to health and wellness issues.
He features on 567CapeTalk, and is a regular guest on SABC3 and the Expresso show. Dr Green works as an emergency medical practitioner at a leading Cape Town hospital and completed four years of training as a registrar in the specialisation of neurology.
If you’ve got medical problems, contact the doctor at [email protected], 021 930 0655 or Twitter @drdarrengreen. Catch him in Cape Town on 567 CapeTalk, most Fridays at 1.30pm.
The advice in this column does not replace a consultation and clinical evaluation with a doctor.
Cape Argus