A headache category that often seems to be disregarded is the painful cranial neuropathies contributing to the scalp and facial pain.

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Neuralgia is pain caused by damage to a nerve or irritation. These conditions are commonly misdiagnosed and difficult to manage by even the most experienced clinicians. This is why it is crucial to be seen by a headache specialist or neurologist.

What is Trigeminal Neuralgia?

Trigeminal Neuralgia (TGN), also known as tic douloureux, is the most common chronic cause of facial pain syndrome. Pain is abrupt in onset and termination, characterized as recurrent one-sided electric shock-like or stabbing pain.

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Epidemiology

TGN is a rare condition that is more prevalent in women over the age of 50. Although the incidence of TGN is less than 0.1%, it is one of the more common neuralgias in the older adult population.

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Anatomy

The trigeminal nerve is one of the largest of the 12 cranial nerves. It transmits sensory information from the skin, sinuses, and mucous membranes of the face. It also stimulates movement and sensation of the jaw muscles and some of the muscles within the inner ear.

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The three major branches of the trigeminal nerve include the ophthalmic (V1), maxillary (V2), and mandibular (V3) nerves (see diagram).

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Causes

In the younger population, the main mechanism of trigeminal neuralgia is structural compression to the trigeminal nerve root. This is confirmed by imaging that identifies a vascular loop around the nerve.

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Another cause is multiple sclerosis, where demyelination occurs in one or more of the trigeminal nerve pathways.

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Often TGN occurs spontaneously although facial trauma, and dental procedures have been seen to be associated with the onset.

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Symptoms

TGN is characterized by recurrent paroxysmal attacks that are abrupt in onset and termination. Pain is one-sided and often described as electric shock-like or stabbing pain. Most commonly affects the 2nd and 3rd divisions of the trigeminal nerve.

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A majority of patients with TGN experience trigger areas in the distribution of the affected nerve. Even light touch to these areas can often trigger an attack. Common triggers include cold air, wind, talking, chewing, smiling, brushing the teeth, shaving, and smoking.

How to make the diagnosis?

A. Recurrent paroxysmal attacks of unilateral facial pain in the distribution of one or more divisions of the trigeminal nerve, and fulfilling criteria B and C (below)

B. Pain has all of the following characteristics:

a. lasting from a fraction of a second to 2 minutes

b. severe intensity

c. electric shock-like, shooting, stabbing, or sharp in quality

C. Attacks are stereotyped in the individual patient.

D. There is no clinically evident neurological deficit. No muscle weakness.

E. Not attributed to another disorder.

Treatment

First-line therapy includes anti-seizure agents such as carbamazepine or oxcarbazepine. For patients who do not respond to initial treatment or cannot tolerate these medications, we often proceed to alternative medications such as lamotrigine, topiramate, and gabapentin. Other options include muscle relaxants such as baclofen or tizanidine.

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SPG nerve blocks can be performed in a medical office to target the branch of the trigeminal nerve behind the nose. Additional treatment may be necessary for those who are refractory to medical therapy, and it may be reasonable to consider microvascular decompression. Gamma Knife radiation is also a non-invasive treatment found to be effective for patients who have not found relief with medications or other forms of therapy.

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If you are looking to get the correct diagnosis and effective treatment, join Neura Health and schedule a video appointment with a board-certified neurologist specializing in headache medicine, who will help you understand your options and better manage this condition.

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