Download Pinky S. Tiwari, MD, PA

Pinky S. Tiwari, M.D., P.A.
Diplomate, American Board of Neurology
Diplomate, American Board of Electrodiagnostic Medicine
St. Luke’s Medical Tower
6624 Fannin, Suite 2190
Houston, TX 77030
Telephone: (713) 790 – 1775
www.texasneuro.com
Fax: (713) 790 – 1605
Trigeminal Neuralgia (Tic Douloureux)
Trigeminal neuralgia, also known as tic douloureux, is a painful disorder of a nerve in the face called the
trigeminal nerve or fifth cranial nerve. There are two trigeminal nerves, one on each side of the face. They are
responsible for detecting touch, pain, temperature and pressure sensations in areas of the face between the
jaw and forehead.
People who have trigeminal neuralgia typically experience episodes of sudden, intense, "stabbing" or
"shocklike" facial pain. This pain can occur almost anywhere between the jaw and forehead, including inside
the mouth. However, it usually is limited to one side of the face.
In some cases, the cause of trigeminal neuralgia is unknown. In many people, however, the disorder seems to
be related to a local irritation of the trigeminal nerve, usually in the area of the nerve root deep within the skull.
In most cases, the source of this irritation is believed to be an abnormal blood vessel pressing on the nerve.
Less often, the nerve irritation is related to a tumor that involves the brain or nerves, or to a rare type of stroke.
In addition, up to 8 percent of patients who suffer from multiple sclerosis (MS) eventually develop trigeminal
neuralgia as a result of MS-related nerve damage.
New cases of trigeminal neuralgia affect four to five out of every 100,000 people in the United States each
year. It affects women slightly more often than men, perhaps because the disease is most common in older
people and women live longer. In most cases, the first episode of facial pain occurs when the patient is 50 to
70 years old. Although infants, children and young adults may develop this disorder, it is rare in people
younger than age 40.
Symptoms
Trigeminal neuralgia causes episodes of sudden, intense facial pain that usually last for two minutes or less. In
most cases, the pain is described as excruciating, and its quality is "sharp," "stabbing," "piercing," "burning,"
"like lightning" or "like an electric shock." In most cases, only one side of the face is affected.
The pain of trigeminal neuralgia is recognized as one of the most excruciating forms of pain known. The pain
often is triggered by nonpainful facial movements or stimuli, such as talking, eating, washing the face, brushing
the teeth, shaving or touching the face lightly. In some cases, even a gentle breeze on the cheek is enough to
trigger an attack. Approximately 50 percent of patients also have specific trigger points or zones on the face,
usually located somewhere between the lips and nose, where an episode of trigeminal neuralgia can be
triggered by a touch or a temperature change. In some cases, a sensation of tingling or numbness comes
before the pain.
Attacks of trigeminal neuralgia can vary significantly, and may occur in clusters, with several episodes following
in series over the course of a day. For unknown reasons, trigeminal neuralgia almost never occurs at night
when the person is sleeping.
In addition to pain, some patients simultaneously have a cheek twitch or muscle spasm, wincing, a facial flush,
a tearing eye or salivation on the same side of the face. It is the facial muscle spasms that led to the older
term, tic douloureux (in French, tic means muscle twitch or spasm; douloureux means painful).
Diagnosis
Your doctor will ask about your symptoms and your medical history, including any history of multiple sclerosis,
a condition that may cause similar or even identical symptoms. To help rule out medical and dental conditions
that can mimic trigeminal neuralgia, the doctor also asks whether you have a history of:
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Recent trauma to your face or teeth
A recent tooth infection or root canal treatment
A tooth extraction on the same side as your facial pain — Sometimes a tooth extraction can cause pain
in the area of the missing tooth.
Any areas of painful facial blisters — Painful blisters can be a sign that you have a viral infection
involving your facial skin, such as herpes (which is caused by the herpes simplex virus) or shingles
(which is caused by varicella zoster, the chickenpox virus). Facial pain can persist for weeks after the
blisters heal, especially in cases of shingles.
Next, your doctor will thoroughly examine your head and neck, including the area inside your mouth. The
doctor also will do a brief neurological examination and concentrate on feeling and muscle movements in your
face. In almost all cases of trigeminal neuralgia, the results of these examinations are normal. If necessary,
your doctor will order a magnetic resonance imaging (MRI) or computed tomography (CT) scan of your head to
check for blood vessel abnormalities, tumors pressing on your trigeminal nerve or other possible causes of
your symptoms.
Your doctor will diagnose trigeminal neuralgia based on your symptoms, the examination and test results.
There is no specific test to confirm the diagnosis of trigeminal neuralgia, so an important part of the diagnosis
is excluding other explanations for the symptoms. In some cases, the doctor prescribes a brief course of
carbamazepine (Tegretol and others), which is used to treat trigeminal neuralgia. A good response to this
medication supports the diagnosis of trigeminal neuralgia.
Expected Duration
Trigeminal neuralgia is unpredictable. For unknown reasons, many people experience periods when the illness
suddenly intensifies and produces repeated painful episodes over the course of several days, weeks or
months. This period may be followed by a pain-free interval that can last for months or years.
The type of treatment that you receive may influence the duration of your symptoms. Some treatments carry a
higher risk that the symptoms will return.
Prevention
Because the cause of trigeminal neuralgia is unknown, it cannot be prevented.
Treatment
The first treatment for trigeminal neuralgia usually is carbamazepine (Tegretol and others). Carbamazepine is
an anticonvulsant medication that decreases the ability of the trigeminal nerve to fire off the nerve impulses
that cause facial pain. If carbamazepine is not effective, other possible drug choices include phenytoin
(Dilantin), baclofen (Lioresal), gabapentin (Neurontin), lamotrigine (Lamictal), clonazepam (Klonopin) and
valproic acid (Depakene, Depakote). These may be taken individually or in combination. One study found that
when trigeminal neuralgia is related to multiple sclerosis, misoprostol (Cytotec), a medication usually
prescribed to prevent stomach ulcers, may be effective. Narcotic pain relievers, such as oxycodone
(OxyContin) or morphine (several brand names), may be recommended briefly for severe episodes of pain.
Some of these medications carry the risk of unpleasant side effects, including drowsiness, liver problems,
blood disorders, nausea, dizziness, overgrowth of the gums and skin rashes. For this reason, people taking
any of these medications may be monitored with frequent follow-up visits and periodic blood tests. After a few
pain-free months, your doctor may attempt to decrease the dose of the medication gradually or discontinue it.
This is done to limit the risk of side effects and to determine whether your trigeminal neuralgia has gone away
on its own.
If medication does not stop your pain or if you cannot tolerate the side effects of medication, then your doctor
may suggest one of the following treatment options:
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Rhizolysis (selective destruction of part of the trigeminal nerve) — In this approach, a portion of the
trigeminal nerve is inactivated temporarily by using one of the following methods: a heated probe, an
injection of the chemical glycerol or a tiny balloon that is inflated near the nerve to compress it. During
the procedure a needle or a tiny hollow tube called a trocar is inserted through the skin of your cheek.
These procedures provide immediate relief in up to 99 percent of patients, but 25 percent to 50 percent
of people will have the problem return during the next several years.
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Stereotactic radiosurgery — This form of radiation therapy uses a linear accelerator or a gamma
knife to inactivate part of the trigeminal nerve. After your head is positioned carefully in a special head
frame, many tiny beams of radiation are aimed precisely at the portion of the trigeminal nerve that must
be inactivated. Stereotactic radiosurgery is a fairly new treatment option for trigeminal neuralgia, and its
long-term success rate is still being evaluated.
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Microvascular decompression of the trigeminal nerve — In this delicate surgical procedure, a
surgeon carefully repositions the blood vessel that is pressing on your trigeminal nerve near your brain.
Because this procedure involves opening your skull, the ideal candidate for this procedure is someone
who is generally healthy and younger than 65. Overall, the immediate success rate is approximately 90
percent, and 70 percent to 80 percent of patients have long-term relief. Microvascular decompression
may be effective for patients who have not had success with one of the less invasive surgeries.
When To Call A Professional
You should seek medical help immediately if you develop facial pain that fits the pattern of trigeminal neuralgia.
Prognosis
In most cases, the prognosis is good. Approximately 80 percent of patients become pain free with medication
alone. When medication fails or produces unwanted side effects, other treatment options are available and
also have a high rate of success.
Trigeminal Neuralgia Association
P.O. Box 340
603 Broadway
Barnegat Light, NJ 08006
Phone: (904) 779-0333
http://www.tna-support.org/
National Institute of Neurological Disorders and Stroke
P.O. Box 5801
Bethesda, MD 20824
Toll-Free: (800) 352-9424
http://www.ninds.nih.gov/
American Academy of Neurology (AAN)
1080 Montreal Ave.
St. Paul, MN 55116
Phone: (651) 695-2717
Toll-Free: (800) 879-1960
Fax: (651) 695-2791
http://www.aan.com/