Clinician-to-Clinician Update Clinician-to-Clinician Update

Finding Effective Treatment for Debilitating Facial Pain

July 2016

Trigeminal neuralgia (TN) is a “chronic pain condition that causes extreme, sporadic, sudden burning or shock-like face pain.”1 TN pain, which seldom lasts more than a minute or two per episode, is most often felt on one side of the jaw or cheek. The pain is frequently severe, many describing it as feeling like an electric shock or ice pick jabbing the side of their face. Attacks can be triggered by talking, chewing, teeth brushing, or a light touch to the face. In 95% of cases of TN, vascular pressure affects the trigeminal nerve as it exits the brain stem.2 TN symptoms also can be associated with multiple sclerosis, pain complication from shingles, and vascular anomalies at the root of the nerve.3

TN is significantly more common as people age. The incidence of TN is 4.3/100,000, the peak incidence is in age group 60–69, and it is rare in patients under the age of 40.4 As a result, primary providers often do not recognize TN symptoms in younger patients.

Some TN patients have multiple compounding conditions such as migraine, sinus issues, earaches, jaw pain (TMD), and dental disorders. Pain associated with TN can reduce productivity in employment, impair other activities of daily living, and lead to depression.5

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— Research into skull anatomy may inform surgical approaches to trigeminal neuralgia. University of Minnesota Health neurosurgeon Andrew Grande pictured.

Anticonvulsant medicines, which slow the trigeminal nerve’s ability to conduct pain signals, are usually the first line of treatment for TN symptoms. Tegretol (carbamazepine) is considered the most effective pain-relief medicine. But Tegretol can have a greater than 50% failure rate for long-term (5-10 year) pain control, and its potential adverse effects include drowsiness, dizziness, rash, liver damage, and ataxia.6

Surgical treatment for TN is usually reserved for patients for whom drug therapy fails. Several minimally invasive rhizotomy procedures are available in which nerve fibers are damaged to block the transmission of pain. Another open-surgery approach spares the nerve.

In the majority of the rhizotomy procedures, a surgeon approaches the trigeminal nerve using a needle placed percutaneously through the cheek and advancing it through a small hole at the base of the skull toward the nerve ganglion. In radiofrequency thermal lesioning, the surgeon places an electrode that destroys some of the nerve fibers with a small electrical current. Alternately glycerol can be injected to damage the nerve. During a balloon compression procedure, the surgeon inserts a catheter fitted with a balloon. The balloon is then expanded, crushing the nerve. In another approach, clinicians deliver highly focused beams of radiation to the trigeminal nerve where it exits the brain stem. While these approaches are less invasive and can provide relief, they can cause sensory loss and pose a higher risk of condition recurrence.

The nerve-sparing technique, microvascular decompression (MD), according to studies, is the most effective and lasting treatment for TN.7 In most cases of TN, a vessel (artery, vein, or combination of both) compresses the trigeminal nerve at its origin near the brain stem. During MD, the surgeon makes a small hole through the mastoid bone behind the ear. Through the craniotomy, the surgeon identifies the offending vessel and dissects it from the nerve. A small Teflon sponge is then placed to pad the nerve from the moved vessel. This microscopic surgery does not involve removing or damaging any brain or nerve tissue.

When to refer

Inflammation or pressure on the trigeminal nerve can cause moderate-to-severe intermittent pain. Patients who experience symptoms like any of the following may be candidates for a referral to the Facial Pain Clinic:

  • persistent facial pain that is unresponsive to NSAIDs or acetaminophen
  • tooth or jaw pain that persists after a dentist cannot find a cause
  • pain that feels like a “sinus headache” and for which an otolaryngologist (ENT) cannot find a cause

As experts in diagnosing and treating trigeminal neuralgia and facial pain, University of Minnesota Health neurosurgeons and related specialists have a number of treatment approaches to relieve pain. We bring an interdisciplinary, team-based approach to assessing these complex conditions. We’ll conduct a complete examination and history and develop a plan that’s focused on each patient’s unique needs.

Facial Pain Clinic

Meeting once each month (on the second Wednesday), the Facial Pain Clinic brings a cross section of specialists to the assessment and treatment of trigeminal neuralgia and related pain disorders, with a special focus on especially complex cases.

The clinic has four specialists – neurosurgeons (Andrew Grande, MD, and Stephen Haines, MD), an otolaryngologist (Holly Boyer, MD), and an orofacial pain specialist (Donald Nixdorf, DDS) – dedicated to treating these conditions, and it draws on consulting specialists in neurology, neuropsychology, physical therapy, and pharmacy.

Facial pain patients are referred to the Department of Neurosurgery: 612-624-0644 (fax); 612-624-6666 (phone). Irina Gutsalyuk, PA, reviews the records and helps schedule patients in the appropriate clinic.

To view current clinical trials available through University of Minnesota Health providers, visit studyfinder.umn.edu.

References

  1. National Institute of Neurological Disorders and Stroke. “NINDS Trigeminal Neuralgia Information Page.” Last modified November 3, 2015. http://www. ninds.nih.gov/disorders/trigeminal_neuralgia/trigeminal_neuralgia.htm.
  2. Zakrzewska JM, Coakham HB. Microvascular decompression for trigeminal neuralgia. Current Opinion in Neurology. 2012;25(3):296-301. doi:10.1097/wco.0b013e328352c465.
  3. Toledo IPD, Réus JC, Fernandes M, et al. Prevalence of trigeminal neuralgia. The Journal of the American Dental Association. 2016. doi:10.1016/j.adaj.2016.02.014.
  4. Zakrzewska, JM, Nixdorf DR. Trigeminal Neuralgia: Diagnosis and Treatment in R.F. Schmidt, G.F. Gebhart (eds.), Encyclopedia of Pain, DOI 10.1007/978-3-642-28753-4, # Springer-Verlag Berlin Heidelberg 2013.
  5. Tolle T, Dukes E, Sadosky A. Patient Burden of Trigeminal Neuralgia: Results from a Cross-Sectional Survey of Health State Impairment and Treatment Patterns in Six European Countries. Pain Practice. 2006;6(3):153-160. doi:10.1111/j.1533-2500.2006.00079.x.
  6. Zakrzewska JM, Linskey ME. Trigeminal neuralgia. Bmj 2014; 348(feb17 9). doi:10.1136/bmj.g474.
  7. Zakrzewska JM, Linskey ME. Trigeminal neuralgia. Bmj 2015;350(mar12 4). doi:10.1136/bmj.h1238.
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