Trigeminal Neuralgia
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La Neuralgia del Trigémino
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What is trigeminal neuralgia?What is trigeminal neuralgia? Trigeminal neuralgia (TN), also called tic douloureux, is a chronic pain condition that affects the trigeminal or 5th cranial nerve, one of the largest nerves in the head. The
disorder causes extreme, sporadic, sudden burning or shock-like face pain that lasts anywhere from a few seconds to as long
as 2 minutes per episode. These attacks can occur in quick succession. The intensity of pain can be physically and mentally incapacitating.
The trigeminal nerve is one of 12 pairs of cranial nerves that originate at the base of the brain. The nerve has three branches
that conduct sensations from the upper, middle, and lower portions of the face, as well as the oral cavity, to the brain.
The ophthalmic, or upper, branch supplies sensation to most of the scalp, forehead, and front of the head. The maxillary,
or middle, branch passes through the cheek, upper jaw, top lip, teeth and gums, and to the side of the nose. The nerve’s
mandibular, or lower, branch passes through the lower jaw, teeth, gums, and bottom lip. More than one nerve branch can be
affected by the disorder.
What causes trigeminal neuralgia? The presumed cause of TN is a blood vessel pressing on the trigeminal nerve as it exits the brainstem. This compression causes the wearing away of the protective coating around the nerve (the myelin sheath). TN may be part of the normal aging process—as blood vessels lengthen they can come to rest and pulsate against a nerve. TN symptoms can also occur in people with multiple sclerosis, a disease caused by the deterioration of myelin throughout
the body, or may be caused by damage to the myelin sheath by compression from a tumor. This deterioration causes the nerve to send abnormal signals to the brain. In some cases the cause is unknown.
What are its symptoms? TN is characterized by a sudden, severe, electric shock-like, stabbing pain that is typically felt on one side of the jaw
or cheek. Pain may occur on both sides of the face, although not at the same time. The attacks of pain, which generally
last several seconds and may repeat in quick succession, come and go throughout the day. These episodes can last for days,
weeks, or months at a time and then disappear for months or years. In the days before an episode begins, some patients may
experience a tingling or numbing sensation or a somewhat constant and aching pain.
The intense flashes of pain can be triggered by vibration or contact with the cheek (such as when shaving, washing the face,
or applying makeup), brushing teeth, eating, drinking, talking, or being exposed to the wind. The pain may affect a small
area of the face or may spread. The bouts of pain rarely occur at night, when the patient is sleeping.
Patients are considered to have Type 1 TN if more than 50 percent of the pain they experience is sudden, intermittent, sharp
and stabbing, or shock-like. These patients may also have some burning sensation. Type 2 TN involves pain that is constant,
aching, or burning more than 50 percent of the time.
TN is typified by attacks that stop for a period of time and then come back. The attacks often worsen over time, with fewer
and shorter pain-free periods before they recur. The disorder is not fatal, but can be debilitating. Due to the intensity
of the pain, some patients may avoid daily activities because they fear an impending attack.
Who is affected? TN occurs most often in people over age 50, but it can occur at any age. The disorder is more common in women than in men.
There is some evidence that the disorder runs in families, perhaps because of an inherited pattern of blood vessel formation.
How is TN diagnosed? There is no single test to diagnose TN. Diagnosis is generally based on the patient’s medical history and description of
symptoms, a physical exam, and a thorough neurological examination by a physician. Other disorders, such as post-herpetic
neuralgia, can cause similar facial pain, as do syndromes such as cluster headaches. Injury to the trigeminal nerve (perhaps
the result of sinus surgery, oral surgery, stroke, or facial trauma) may produce neuropathic pain, which is characterized
by dull, burning, and boring pain. Because of overlapping symptoms, and the large number of conditions that can cause facial
pain, obtaining a correct diagnosis is difficult, but finding the cause of the pain is important as the treatments for different
types of pain may differ.
Most TN patients undergo a standard magnetic resonance imaging scan to rule out a tumor or multiple sclerosis as the cause
of their pain. This scan may or may not clearly show a blood vessel on the nerve. Magnetic resonance angiography, which
can trace a colored dye that is injected into the bloodstream prior to the scan, can more clearly show blood vessel problems
and any compression of the trigeminal nerve close to the brainstem.
How is it treated? Treatment options include medicines, surgery, and complementary approaches. Anticonvulsant medicines—used to block nerve firing—are generally effective in treating TN. These drugs include carbamazepine,
oxcarbazepine, topiramate, clonazepam, phenytoin, lamotrigin, and valproic acid. Gabapentin or baclofen can be used as a
second drug to treat TN and may be given in combination with other anticonvulsants.
Tricyclic antidepressants such as amitriptyline or nortriptyline are used to treat pain described as constant, burning, or
aching. Typical analgesics and opioids are not usually helpful in treating the sharp, recurring pain caused by TN. If medication
fails to relieve pain or produces intolerable side effects such as excess fatigue, surgical treatment may be recommended.
Several neurosurgical procedures are available to treat TN. The choice among the various types depends on the patient's preference,
physical well-being, previous surgeries, presence of multiple sclerosis, and area of trigeminal nerve involvement (particularly
when the upper/ophthalmic branch is involved). Some procedures are done on an outpatient basis, while others may involve
a more complex operation that is performed under general anesthesia. Some degree of facial numbness is expected after most
of these procedures, and TN might return despite the procedure’s initial success. Depending on the procedure, other surgical
risks include hearing loss, balance problems, infection, and stroke.
A rhizotomy is a procedure in which select nerve fibers are destroyed to block pain. A rhizotomy for TN causes some degree of permanent
sensory loss and facial numbness. Several forms of rhizotomy are available to treat TN:
Microvascular decompression is the most invasive of all surgeries for TN, but it also offers the lowest probability that pain will return. This inpatient
procedure, which is performed under general anesthesia, requires that a small opening be made behind the ear. While viewing
the trigeminal nerve through a microscope, the surgeon moves away the vessels that are compressing the nerve and places a
soft cushion between the nerve and the vessels. Unlike rhizotomies, there is usually no numbness in the face after this surgery.
Patients generally recuperate for several days in the hospital following the procedure. A neurectomy, which involves cutting part of the nerve, may be performed during microvascular decompression if no vessel is found to be
pressing on the trigeminal nerve. Neurectomies may also be performed by cutting branches of the trigeminal nerve in the face.
When done during microvascular decompression, a neurectomy will cause permanent numbness in the area of the face that is supplied
by the nerve or nerve branch that is cut. However, when the operation is performed in the face, the nerve may grow back and
in time sensation may return.
Some patients choose to manage TN using complementary techniques, usually in combination with drug treatment. These therapies
offer varying degrees of success. Options include acupuncture, biofeedback, vitamin therapy, nutritional therapy, and electrical
stimulation of the nerves.
What research is being done? The National Institute of Neurological Disorders and Stroke (NINDS), a part of the National Institutes of Health, is the federal
government’s leading supporter of biomedical research on disorders of the brain and nervous system. One NINDS-funded study
is examining the neurophysiological characteristics of TN to see if the disorder is associated with abnormal sensory input
from the peripheral nervous system. Observations from this study should allow scientists to better understand the nerve cell
mechanisms of TN, develop better animal models of the disorder, and find better medical and surgical treatments for TN and
other nerve pain disorders. Other NINDS-funded projects address TN through studies associated with pain research.
Some NIH-funded research examines functional and chemical changes in sensory neurons in the peripheral and central nervous
systems, and evaluates the roles of nerve growth factor and sympathetic nerves in the development of neuropathic pain.
For more information on neurological disorders or research programs funded by the National Institute of Neurological Disorders and Stroke, contact the Institute's Brain Resources and Information Network (BRAIN) at:
BRAIN
P.O. Box 5801
Bethesda, MD 20824
(800) 352-9424
http://www.ninds.nih.gov
Information also is available from the following organizations:
Trigeminal Neuralgia Association 925 Northwest 56th Terrace Suite C Gainesville, FL 32605 info@fpa-support.org http://www.endthepain.org Tel: 352-331-7009 800-923-3608 Fax: 352-331-7078 |
International RadioSurgery Association 3002 N. Second Street Harrisburg, PA 17110 office1@irsa.org http://www.irsa.org Tel: 717-260-9808 Fax: 717-260-9809 |
American Chronic Pain Association (ACPA) P.O. Box 850 Rocklin, CA 95677-0850 ACPA@pacbell.net http://www.theacpa.org Tel: 916-632-0922 800-533-3231 Fax: 916-632-3208 |
American Pain Foundation 201 North Charles Street Suite 710 Baltimore, MD 21201-4111 info@painfoundation.org http://www.painfoundation.org Tel: 888-615-PAIN (7246) Fax: 410-385-1832 |
National Foundation for the Treatment of Pain P.O. Box 70045 Houston, TX 77270 NFTPain@cwo.com http://www.paincare.org Tel: 713-862-9332 Fax: 713-862-9346 |
NIH Publication No. 06-5116
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Last updated July 31, 2008