Understanding Trigeminal Neuralgia
By: Brian Hoeflinger, MD
November 24, 2024 | #24
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Disclaimer: Opinions are my own. Not medical advice.
Medical Trivia of the Week
In trigeminal neuralgia, the protective covering of the trigeminal nerve is often damaged. What is this covering called? (the correct answer is at the end of this email)
- A) Myelin sheath
- B) Axon sheath
- C) Dura mater
- D) Pia mater
What is Trigeminal Neuralgia?
Often the best way to understand something is by describing a real life situation. I recently saw a patient in the office for lower back problems. When I walked into the room, the patient's wife greeted me and said hello. The patient said nothing. The wife smiled at me and her husband elicited no facial expression. I asked the man if something was wrong and he wouldn’t answer. His face was motionless, except for intermittent muscle twitches. The situation was odd to say the least until I further asked what was wrong and his wife said he suffers from Trigeminal neuralgia (TN) and has been having constant attacks of facial pain for the past 2 to 3 days. The twitches of his face were actually winces of excruciating pain. He did not dare to move his face, smile, or talk in fear of another attack of pain. His wife told me he has not been eating, brushing his teeth, or washing his face in fear of pain. That is what Trigeminal neuralgia is.
Trigeminal neuralgia is a chronic pain condition that affects the trigeminal nerve, one of the main cranial nerves responsible for sensation in the face. People with this condition experience sudden, severe, stabbing, or shock-like facial pain that can last from seconds to minutes. Even routine activities like eating, speaking, or touching the face can trigger excruciating pain episodes. While TN is rare, it has a profound impact on the quality of life for those it affects. Understanding the condition is the first step in managing it effectively.
Causes and Risk Factors
Trigeminal neuralgia is typically caused by compression of the trigeminal nerve, often by an artery or vein near the brainstem. This compression damages the protective myelin sheath around the nerve, leading to erratic and hyperactive nerve signals.
Other potential causes include:
- Multiple sclerosis, which can damage the myelin sheath.
- Brain tumors pressing on the trigeminal nerve.
- Injuries or trauma to the face or nerve.
Risk factors include:
- Age: TN is more common in people over 50 years old.
- Gender: Women are more likely to be affected than men.
- Family History: A genetic predisposition may increase the likelihood of developing TN.
Symptoms of Trigeminal Neuralgia
The hallmark symptom of TN is severe facial pain, but it can manifest in various ways:
- Sharp, Electric-Shock Pain: Often localized to one side of the face, affecting areas innervated by the trigeminal nerve.
- Pain Triggers: Common triggers include chewing, brushing teeth, talking, or even a light breeze on the face.
- Recurrent Episodes: Pain may come and go, with symptom-free periods lasting days, weeks, or months.
- Progression: Over time, episodes may become more frequent and less responsive to treatment.
Diagnosis
Diagnosing TN requires a thorough medical history and physical exam. Imaging studies like MRI may be used to rule out underlying causes such as tumors or multiple sclerosis. The diagnosis is often clinical, based on the specific pattern of pain and its triggers.
Treatment Options
Although TN is challenging to treat, many options are available to manage symptoms:
-
Medications:
- Anticonvulsants: Drugs like carbamazepine, oxcarbazepine, and Lamictal are commonly used to calm overactive nerve signals.
- Muscle Relaxants: Baclofen can sometimes help.
- Pain Relievers: While helpful for some, standard pain medications are often ineffective.
- Other Medications: Lyrica and Neurontin are sometimes used as well to help relieve symptoms of TN.
-
Minimally Invasive Procedures:
- Glycerol Injection and RF Rhizotomy: Targets nerve pain by damaging the nerve’s ability to send pain signals.
- Balloon Compression: Applies pressure to the nerve to block pain signals.
-
Surgical Options:
- Microvascular Decompression (MVD): The most definitive treatment, involving the removal or repositioning of the blood vessel pressing on the trigeminal nerve.
- Gamma Knife Radiosurgery: A non-invasive option that uses focused radiation to target the trigeminal nerve.
-
Lifestyle and Support:
- Stress management techniques, such as mindfulness or meditation, may reduce the frequency and intensity of pain episodes.
- Support groups can provide a sense of community and coping strategies.
Our Podcast Episode on Trigeminal Neuralgia
Learn more from the previous podcast Kevin and I did on Trigeminal Neuralgia (links to the episode below):
YouTube, Spotify, Apple Podcasts, Everywhere else
Final Thoughts
Trigeminal neuralgia highlights the intricate nature of the human body and the power of knowledge in addressing even the most challenging conditions. Though TN can be life-altering, understanding the condition and exploring effective treatment options can help patients reclaim control and improve their quality of life. If you or someone you know is struggling with TN, consult a healthcare professional to explore your options and find the best treatment plan. Lastly, please share this newsletter if you know someone who might benefit from it!
Impactful Quote of the Week
"The human spirit is stronger than anything that can happen to it.”
- C.C. Scott
All the best,
Brian Hoeflinger
P.S. - if you enjoyed this newsletter, you may enjoy my book that details my life as neurosurgeon and the loss of my oldest son, Brian (see below a synopsis).
My Book
Life and Death . . . Two words with such opposite meaning and which inflict such contradictory emotions and yet are so closely intertwined in our lives. As parents, we bring meaning and life into this world through our children. Our lives become defined as a result. We learn the joy, hardship, and responsibility of shaping an innocent life. But a day will come when that life will be taken. For some, death will come too soon. This is the story of my son, Brian Nicholas Hoeflinger, who died unexpectedly at age 18.
https://doctorhoeflinger.com/products/the-night-he-died-the-harsh-reality-of-teenage-drinking
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Medical Trivia Answer:
The correct answer is A) Myelin Sheath. The myelin sheath insulates nerve fibers, allowing smooth and rapid signal transmission. In trigeminal neuralgia, damage to the myelin sheath causes erratic nerve signaling, leading to severe, shock-like facial pain.
