Trigeminal Neuralgia

Trigeminal neuralgia, often called tic douloureux, is a craniofacial pain disorder characterized by episodes of severe, sharp, lancinating, "electric-like" bolts of pain. Trigeminal neuralgia is either classic / idiopathic (primary) or due to a structural lesion involving the trigeminal system or associated with some other neurologic process (secondary).

Classic / idiopathic trigeminal neuralgia typically occurs in persons over the age of 50, is more common in females, is predominately unilateral, has tactile (light touch) "trigger" areas, does not produce a neurosensory deficit (numbness), and is restricted to the distribution of the trigeminal nerve. The pain attacks can occur spontaneously or can be triggered by a stimulus to the skin, intraoral mucosa, and very often the teeth. Often there are bouts of pain followed by remission periods.

The initial evaluation of patients with the above clinical presentation should include: a comprehensive history, complete physical examination with special attention to the head and neck exam and neurological exam and appropriate diagnostic testing. Imaging studies (MRI) are employed to evaluate for the presence of a tumor, blood vessel abnormality, multiple sclerosis or another disorder that might be damaging the trigeminal system.

Numerous management approaches have been and are still currently available for the treatment of trigeminal neuralgia. Most of these are effective, yet trigeminal neuralgia remains sometimes difficult to manage due to the fact that the cause remains unknown and therefore no universally accepted medical and surgical management protocol is available.

Treatment should be prescribed based upon a logical and systematic diagnostic and therapeutic protocol. We have developed such a protocol that combines comprehensive evaluation, medical and surgical management.

Current treatment strategies consist of medical management and surgical management. Medical management consists of pharmacologic and non-pharmacologic approaches, while surgical management consists of numerous peripheral and intracranial procedures. The first line of treatment to help relieve the pain is usually medical therapy, with the anticonvulsant/antiepileptic class of drugs. These include:

• Carbamazepine (Tegretol)
• Oxcarbazepine (Trileptal)
• Tiagabine (Gabatril)
• Zonisamide (Zonegran)
• Topiramate (Topamax)
• Baclofen (Lioresal)
• Clonazepam (Klonopin)
• Gabapentin (Neurontin)
• Lamotrigine (Lamactil)
• Pregabalin (Lyrica)

Pharmacologic therapy is effective in the majority of patients; however, for some patients these medications do not eliminate the pain and / or can produce significant side effects, which can be disruptive to the functions of daily living or could be potentially harmful. If medical therapy is unsuccessful, or not tolerated, surgical treatment should be considered.

Numerous surgical procedures have been advocated to treat trigeminal neuralgia. Currently, the most common surgical procedures are percutaneous radiofrequency thermal ablation of the trigeminal nerve, intracranial microvascular decompression of the nerve and non-invasive gamma knife radiosurgery of the nerve.

The Division of Oral and Maxillofacial Pain has several faculty members who are experts in trigeminal neuralgia; they have experience successfully treating hundreds of patients with both medical and surgical techniques.

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Mathews ES, Scrivani SJ: Surgical Treatment of Trigeminal Neuralgia with Percutaneous Stereotactic Radiofrequency Thermal Rhizotomy. The Mount Sinai Journal of Medicine. 67:283-299, 2000.

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Scrivani SJ, Mathews ES, Maciewicz RJ: Trigeminal Neuralgia: A Medical Management Update. Oral Surg, Oral Med, Oral Path., 100:527-538, Nov. 2005.

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