TRIGENMINAL NEURAGIA

Trigeminal neuralgia is sudden, severe facial pain. It’s often described as a sharp shooting pain or like having an electric shock in the jaw, teeth or gums.

 

It usually happens in short, unpredictable attacks that can last from a few seconds to about 2 minutes. The attacks stop as suddenly as they start.

 

In most cases, trigeminal neuralgia affects just one side of the face, with the pain usually felt in the lower part of the face. Very occasionally the pain can affect both sides of the face, although not usually at the same time.

 

Diagram of trigeminal nerveCredit:

People with the condition may experience attacks of pain regularly for days, weeks or months at a time. In severe cases attacks may happen hundreds of times a day.

 

It’s possible for the pain to improve or even disappear altogether for several months or years at a time (remission), although these periods tend to get shorter with time.

 

Some people may then develop a more continuous aching, throbbing or burning sensation, sometimes accompanied by the sharp attacks.

 

Living with trigeminal neuralgia can be very difficult. It can have a significant impact on a person’s quality of life, resulting in problems such as weight loss, isolation and depression.

 

Read more about the symptoms of trigeminal neuralgia.

 

When to seek medical advice

See a GP if you experience frequent or persistent facial pain, particularly if standard painkillers, such as paracetamol and ibuprofen, do not help and a dentist has ruled out any dental causes.

 

The GP will try to identify the problem by asking about your symptoms and ruling out conditions that could be responsible for your pain.

 

However, diagnosing trigeminal neuralgia can be difficult and it can take a few years for a diagnosis to be confirmed.

 

Read more about diagnosing trigeminal neuralgia.

 

What causes trigeminal neuralgia?

Trigeminal neuralgia is usually caused by compression of the trigeminal nerve. This is the nerve inside the skull that transmits sensations of pain and touch from your face, teeth and mouth to your brain.

 

The compression of the trigeminal nerve is usually caused by a nearby blood vessel pressing on part of the nerve inside the skull.

 

Trigeminal neuralgia can also happen when the trigeminal nerve is damaged by another medical condition, such as multiple sclerosis (MS) or a tumour.

 

The attacks of pain are usually brought on by activities that involve lightly touching the face, such as washing, eating and brushing the teeth, but they can also be triggered by wind – even a slight breeze or air conditioning – or movement of the face or head. Sometimes the pain can happen without a trigger.

 

Read more about the causes of trigeminal neuralgia.

 

Who’s affected

It’s not clear how many people are affected by trigeminal neuralgia, but it’s thought to be rare, with around 10 people in 100,000 in the UK developing it each year.

 

Trigeminal neuralgia affects more women than men, and it usually starts between the ages of 50 and 60. It’s rare in adults younger than 40.

 

Treating trigeminal neuralgia

Trigeminal neuralgia is usually a long-term condition and the periods of remission often get shorter over time. However, the treatments available do help most cases to some degree.

 

An anticonvulsant medicine called carbamazepine, which is often used to treat epilepsy, is the first treatment usually recommended to treat trigeminal neuralgia. Carbamazepine can relieve nerve pain by slowing down electrical impulses in the nerves and reducing their ability to transmit pain messages.

 

Carbamazepine needs to be taken several times a day to be effective, with the dose gradually increased over the course of a few days or weeks so high enough levels of the medicine can build up in your bloodstream.

 

Unless your pain becomes much better, or disappears, the medicine is usually continued for as long as necessary, which could be for many years.

 

If you’re entering a period of remission, where your pain goes away, stopping carbamazepine should always be done slowly, over days or weeks, unless a doctor tells you otherwise.

 

If this medicine does not help you, causes too many side effects, or you’re unable to take it, you may be referred to a specialist to discuss alternative medicines or surgical procedures that may help.

 

There are a number of minor surgical procedures that can be used to treat trigeminal neuralgia – usually by damaging the nerve to stop it sending pain signals – but these are generally only effective for a few years.

 

Alternatively, your specialist may recommend having surgery to open your skull and move any blood vessels that are compressing the trigeminal nerve. Research suggests this operation offers the best results for long-term pain relief, but it’s a major operation and carries a risk of potentially serious complications, such as hearing loss, facial numbness or, very rarely, a stroke.

 

Read more about treating trigeminal neuralgia.

 

Post-herpetic neuralgia

Post-herpetic neuralgia is a more common type of nerve pain that usually develops in an area previously affected by shingles.

 

Symptoms

The main symptom of trigeminal neuralgia is sudden attacks of severe, sharp, shooting facial pain that last from a few seconds to about 2 minutes.

 

The pain is often described as excruciating, like an electric shock. The attacks can be so severe that you’re unable to do anything while they’re happening.

 

Trigeminal neuralgia usually affects one side of the face. In some cases it can affect both sides, although not usually at the same time.

 

The pain can be in the teeth, lower jaw, upper jaw or cheek. Less commonly the pain can also be in the forehead or eye.

 

You may sense when an attack is about to happen, although they usually start unexpectedly.

 

After the most severe pain has subsided you may experience a slight ache or burning feeling. You may also have a constant throbbing, aching or burning sensation between attacks.

 

You may experience regular episodes of pain for days, weeks or months at a time. Sometimes the pain may disappear completely and not return for several months or years. This is known as remission.

 

In severe cases of trigeminal neuralgia the attacks may happen hundreds of times a day and there may be no periods of remission.

 

Symptom triggers

Attacks of trigeminal neuralgia can be triggered by certain actions or movements, such as:

 

talking

smiling

chewing

brushing your teeth

washing your face

a light touch

shaving or putting on make-up

swallowing

kissing

a cool breeze or air conditioning

head movements

vibrations, such as walking or travelling in a car

However, pain can happen spontaneously with no trigger whatsoever.

 

Further problems

Living with trigeminal neuralgia can be very difficult and your quality of life can be significantly affected.

 

You may feel like avoiding activities such as washing, shaving or eating so you do not trigger the pain, and the fear of pain may mean you avoid social activities.

 

However, it’s important to try to live a normal life and be aware that becoming undernourished or dehydrated can make the pain worse.

 

The emotional strain of living with repeated episodes of pain can lead to psychological problems, such as depression. During periods of extreme pain some people may even consider suicide. Even when pain-free, you may live in fear of the pain returning.

 

Read more advice about coping with chronic pain.

 

When to see a GP

You should see a GP if you experience frequent or persistent facial pain, particularly if standard painkillers such as paracetamol and ibuprofen do not help and a dentist has ruled out any dental causes.

 

Trigeminal neuralgia can be difficult to diagnose. The GP will try to identify the problem by asking about your symptoms and ruling out other conditions that could be responsible for your pain.

 

Read more about diagnosing trigeminal neuralgia.

 

Causes

The exact cause of trigeminal neuralgia is not known, but it’s often thought to be caused by compression of the trigeminal nerve, or by another medical condition that affects this nerve.

 

The trigeminal nerve – also called the fifth cranial nerve – provides sensation to the face. You have one on each side.

 

Primary trigeminal neuralgia

Evidence suggests that in up to 95% of cases, trigeminal neuralgia is caused by pressure on the trigeminal nerve close to where it enters the brain stem, the lowest part of the brain that merges with the spinal cord.

 

This type of trigeminal neuralgia is known as primary trigeminal neuralgia.

 

In most cases the pressure is caused by an artery or vein squashing (compressing) the trigeminal nerve. These are normal blood vessels that happen to come into contact with the nerve at a particularly sensitive point.

 

It’s not clear why this pressure can cause painful attacks in some people but not others, as not everyone with a compressed trigeminal nerve will experience pain.

 

It may be that, in some people, the pressure on the nerve wears away its protective outer layer (myelin sheath), which may cause pain signals to travel along the nerve. However, this does not fully explain why some people have periods without symptoms (remission), or why pain relief is immediate after a successful operation to move the blood vessels away from the nerve.

 

Secondary trigeminal neuralgia

Secondary trigeminal neuralgia is the term used when trigeminal neuralgia is caused by another medical condition or problem, including:

 

a tumour

a cyst – a fluid-filled sac

arteriovenous malformation – an abnormal tangle of arteries and veins

multiple sclerosis (MS) – a long-term condition that affects the nervous system

facial injury

damage caused by surgery including dental surgery

Diagnosis

As the pain caused by trigeminal neuralgia is often felt in the jaw, teeth or gums, many people with the condition visit a dentist before going to a GP.

 

The dentist will ask you about your symptoms and give you a dental X-ray to help them investigate your facial pain. They’ll look for common causes of facial pain, such as a dental infection or cracked tooth.

 

Trigeminal neuralgia is often diagnosed by a dentist, but if you have seen a dentist and they could not find an obvious cause of your pain, you should visit a GP.

 

Seeing a GP

There’s no specific test for trigeminal neuralgia, so a diagnosis is usually based on your symptoms and description of the pain.

 

If you’ve experienced attacks of facial pain, the GP will ask you questions about your symptoms, such as:

 

how often do the pain attacks happen

how long do the pain attacks last

which areas of your face are affected

The GP will consider other possible causes of your pain and may also examine your head and jaw to identify which parts are painful.

 

Ruling out other conditions

An important part of the process of diagnosing trigeminal neuralgia involves ruling out other conditions that cause facial pain.

 

By asking about your symptoms and carrying out an examination, the GP may be able to rule out other conditions, such as:

 

migraine

joint pain in the lower jaw

giant cell arteritis (temporal arteritis) – where the medium and large arteries in the head and neck become inflamed and cause pain in the jaw and temples

a possible nerve injury

The GP will also ask about your medical, personal and family history when trying to find the cause of your pain.

 

For example, you’re less likely to have trigeminal neuralgia if you’re under 40 years old. Multiple sclerosis (MS) may be a more likely cause if you have a family history of the condition or you have some other form of this condition.

 

However, trigeminal neuralgia is very unlikely to be the first symptom of MS.

 

MRI scans

If the GP is not sure about your diagnosis or you have unusual symptoms, they may refer you for an MRI scan of your head.

 

An MRI scan uses strong magnetic fields and radio waves to create detailed images of the inside of your body.

 

It can help identify potential causes of your facial pain, such as inflammation of the lining of the sinuses (sinusitis), tumours on one of the facial nerves, or nerve damage caused by MS.

 

An MRI scan may also be able to detect whether a blood vessel in your head is compressing one of the trigeminal nerves, which is thought to be the most common cause of trigeminal neuralgia.

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