Trigeminal Neuralgia

My Personal Cause - Trigeminal Neuralgia

I suffer from a condition called V2 (maxillary) Trigeminal Neuralgia aka (The Suicide Disease). This condition is debilitating, there is nothing you can do to stop it, and there is no cure. It can be controlled intermittently by using medicine combinations but still isnt a guarantee that you wont have pain episodes. It has been dubbed the most painful condition known to the human race, hence the reason it is called The Suicide Disease.

The only way i can describe it is that it feels like someone jerked a 220 electrical wire from the wall and touched it to the right side of my face. The first time it hit me i hit the floor because the pain was so great i thought i was dying, i thought i would be better off dead.


Trigeminal Neuralgia (TN) is a pain syndrome characterized by intermittent, shooting pain in the face along the distribution of the fifth (trigeminal) cranial nerve. The trigeminal nerve is the largest of twelve cranial nerves and has three divisions (ophthalmic, maxillary, and mandibular), also known as (V1, V2 and V3) respectively. These three branches are the major carrier of sensory information from the face to the brain.

Neuralgia, simply means pain; the pain is characteristically intense, sharp, episodic, periodical, excruciating, stabbing and short lasting and often accompanied by a brief facial spasm or tic, hence the French term “tic doulourex”. The distribution of pain is typically unilateral i.e. restricted to one side of the face, and follows the sensory distribution of cranial nerve V, typically along the (V2) and/or the (V3) divisions. Rarely TN may manifest as “status trigeminus”, a rapid successtion of tic-like spasms triggered by seemingly minor stimuli.

The condition is the most frequently occurring of all the nerve pain disorders, TN can occur at any age but usually has its onset in women over fifty, male-to-female ratio is 2:3, and its annual incidence is 4/100,000.

TN is distinct but may often be confused and should be differentiated from other closely similar conditions such as atypical facial pain, glossopharyngeal neuralgia, temporomandibular joint pain, sinusitis, migraine headache, other forms of neuritis, and dental problems. These clinical conditions have to be ruled out to establish the diagnosis of TN.

Causes
The condition occurs due to an abnormality that exists both at the level of the inner nerve fibers which carry nerve sensation and at the lining covering the trigeminal nerve (myelin sheath). The nerve fibers behave like an electrical cable leading to electric, shock-like pain induced by a stimulus consisting of a touch or jerk. TN is observed to run in families suggesting a genetic liability for the disease.

The most common triggering cause of TN is an enlarged looping artery or vein pressing on the trigeminal nerve at the base of the brain close to the pons (a part of the brainstem).

Other causes such as aneurysms, tumors, chronic meningeal inflammation, or other lesions may irritate trigeminal nerve roots at the pons and cause symptoms of TN to occur, these can be identified and ruled out by MRI scan of the brain.

Symptoms
There are 3 branches of the trigeminal nerve: the ophthalmic (V1), maxillary (V2), and mandibular (V3). Most commonly TN occurs along the distribution of the maxillary branch (V2), manifesting itself as a sharp pain which runs along the cheekbone, most of the nose, upper lip, and upper teeth. The next most commonly affected division of the trigeminal is the mandibular branch (V3), affecting the lower cheek, lower lip, and jaw.

Patients become plagued by intermittent severe pain which interferes with common daily activities such as eating and brushing teeth. The condition can lead to irritability, severe anticipatory anxiety, depression, and life-threatening malnutrition.

TN is typically described by the patients as extremely severe episodes of pain. Probably the most painful condition known to the human race! The pain is described as stabbing, excruciating, periodic, as if electric shock is given to certain areas of the face. The pain may appear suddenly, may last for a fraction of second or for a few minutes. In rare cases it may last for a couple of hours, making the patient almost immobile and he/she may not be able to do any other activity until the pain subsides.

The pain may get triggered either without any cause or by certain motions involving the facial muscles. Various “triggers” such as washing the face, brushing the teeth, shaving, applying facial make-up, touching the face, blowing, kissing, chewing etc. may precipitate a pain attack. The most minor stimuli such as a mild light breeze may provoke pain in some patients. The degree and character of pain may vary from patient to patient depending on which of the three divisions of the trigeminal nerve is affected, if medication for pain is being used, the individual pain threshold etc. In almost all cases (97%), pain is restricted to one side of the face.

There is a tendency in TN for spontaneous remission, with pain free intervals of weeks or even months, followed by exacerbations, which makes it difficult to judge the effectiveness of any specific treatment. Exacerbations most commonly occur in fall and spring.

Diagnosis
Although TN is diagnosed by clinical symptoms in the majority of cases, all patients should have an MRI scan of the brain to evaluate for any intracranial abnormality. The conventional MRI scans are not always sufficient to visualize the trigeminal nerve or diagnose the offending blood vessel and a 3-dimensional MRI neuro-imaging technique with contrast injection and thin cuts is often required. Of note that some patients may limit their clinical examination for fear of stimulating a trigger point that will precipitate an episode of pain.

Treatment
The initial treatment for TN is medical and directed toward control of the pain. Anti-convulsive medication is used, the most effective drugs are carbamazepine (Tegretol®) and gabapentin (Neurontin®). They should be started at a low dose and gradually increased with the ideal dosage being that which controls the pain but does not cause side effects. Once the initial pain is controlled it is important to consider the natural history of TN. If during therapy the pain subsides completely for four weeks, it is reasonable to gradually reduce the dosage and see if the TN has gone into remission. If the pain recurs the drug can be re-administered.

Treatment with anticonvulsive medication does not help all patients and has its own shortcomings. It needs to be taken for a long period of time and can have many side effects. For those patients whose symptoms cannot be controlled medically without side effects such as nausea, ataxia, physical sluggishness or mental dullness, or who desire long term relief without medication, surgery is indicated.

Surgical options for TN can be divided into two categories: non-destructive procedures and destructive procedures.

Non-Destructive Procedures
The only non-destructive procedure which reliably relieves the symptoms of TN is surgical decompression of the trigeminal nerve, which can be performed either by open surgery or endoscopically. The procedure involves surgical exploration with direct visualization of the trigeminal nerve at its junction with the pons, followed by moving away any compressing blood vessels and padding the nerve with a small piece of Teflon. The advantage is pain relief without numbness in the majority of patients and usually lasts indefinitely.

Destructive Procedures
There are multiple destructive procedures which are utilized in the treatment of TN. The most common of which are glycerol injections, gamma knife radiation, electrocoagulation, and balloon compression. These procedures are all based on interrupting the pain by way of damaging the trigeminal nerve fibers. Generally the more numbness they produce, the longer they last and the numbness created due to nerve destruction may be permanent.

Prognosis
Over time the pain of TN usually becomes more severe and more frequent, requiring higher dosage and more continuous usage of medications. As a result, many patients whose pain was initially well controlled with medication find over time that they must increase to toxic levels in order to control their pain. At this point, they require surgical intervention.