Instead of waiting for the pain to become intractable or the medications toxic, an individual with trigeminal neuralgia has the option to request early surgery. This has a number of potential advantages:

· Avoid years of medication and intermittent pain

· Avoid facing surgery when old or infirm

· If the person has a vascular loop, early microvascular decompression will increase the possibility of a successful operation with decreased risk of recurrence (evidence suggests better outcomes and lower recurrence rate the shorter the interval between onset of symptoms and nerve decompression)

How To Find Out If You Have a Vascular Loop

The conventional MRI scans used to rule out the presence of a brain tumor or multiple sclerosis as a cause of a patients face pain are not adequate to visualize the trigeminal nerve or an associated blood vessel. Fortunately, the continued improvement in MRI neuro-imaging now makes it possible to visualize both. The technique, which is called 3-D volume acquisition, is performed with contrast injection and utilizes thin cuts (0.8mm), without gaps similar to what was developed for MRI angiography and venography. The trigeminal nerve is easily visualized in the axial plane when the MRI series is centered at the midpoint of the fourth ventricle. To ensure an adequate evaluation, the nerve should be seen on three adjacent cuts. Early studies indicate that when an offending vessel is present it will be detected 80% of the of the time. With continued imaging improvements this percentage will definitely increase. Click here for UCSD Trigeminal Neuralgia Sequence Parameters for Seimens and GE MR Scanners.

Surgical Options: Non-Destructive Procedures

The only non-destructive procedure which reliably relieves the symptoms of Trigeminal Neuralgia is Microvascular Decompression (MVD). This involves surgical exploration with the operating microscope and visualization of the junction where the Trigeminal nerve enters the base of the brain, followed by coagulation or moving and padding away any compressing blood vessels. The advantage is pain relief without numbness in the majority of patients, which usually lasts indefinitely. If the pain recurs after a MVD, which it does in 10-15% of patients, it can usually be controlled with low dose Tegretol® or Neurontin®. If the pain continues, it will require a repeat MVD or one of the destructive procedures.

Surgical Options: Destructive Procedures

There are multiple destructive procedures which are beneficial in the treatment of Trigeminal Neuralgia. The most common of which are glycerol injections, gamma knife radiation, electrocoagulation, and balloon compression. These procedures are all based on interrupting the pain by partial damage to Trigeminal nerve fibers. Generally the more numbness they produce, the longer they last. The specific advantages and disadvantages need to be discussed with the surgeon performing the procedure. These procedures are recommended for patients who have failed MVD or are not candidates for major surgery.

Comments

Treatment is always individualized.  All of the options above should be considered in consultation with a neurosurgeon familiar in their use.

Recommendations

Based on the data currently available, and in an effort to maximize quality of life, we recommend the following:

          Patients with less than 10 year life expectancy

Refer for destructive procedure if pain not controlled medically without significant side effects

          Patients with more than 10 but less than 20 year life expectancy

Consider destructive procedure

May abolish need for continued increasing medications

Will make medical therapy easier even if fails

        Patients with more than 20 year life expectancy

Perform thin cut MRI with 3-D Volume Acquisition

If vessel present recommend MVD

Consideration needs to be given to current life expectancy charts at time of implementation. At this time life expectancy is shown below:

(data from IRS Publication 590, Appendix E, Table 1, December 12, 1999)

When a destructive procedure is required, Gamma Knife stereotactic radiosurgery is the procedure of choice because it is least invasive and has the lowest risk of numbness or other side effects, while producing excellent pain relief in most patients with a low incidence of recurrence.

For additional information, please see Trigeminal Neuralgia: Individualized Surgical Management in the 21st Century.

ARTICLE SECTIONS From the Mayo Clinic. 

Trigeminal neuralgia                       http://www.mayoclinic.com/health/trigeminal-neuralgia/DS00446

Introduction Signs and symptoms Causes When to seek medical advice

Screening and diagnosis Treatment Coping skills

Introduction

Imagine having a jab of lightning-like pain shoot through your face when you brush your teeth or put on makeup. Sound excruciating? If you have trigeminal neuralgia, attacks of such pain are frequent and can often seem unbearable.

You may initially experience short, mild attacks, but trigeminal neuralgia can progress, causing longer, more frequent bouts of searing pain. These painful attacks can be spontaneous, but they may also be provoked by even mild stimulation of your face, including brushing your teeth, shaving or putting on makeup. The pain of trigeminal neuralgia may occur in a fairly small area of your face, or it may spread rapidly over a wider area.

Because of the variety of treatment options available, having trigeminal neuralgia doesn't necessarily mean you're doomed to a life of pain. Doctors usually can effectively manage trigeminal neuralgia, either with medications or surgery.

Signs and symptoms

An attack of trigeminal neuralgia can last from a few seconds to about a minute. Some people have mild, occasional twinges of pain, while other people have frequent, severe, electric-shock-like pain. The condition tends to come and go. You may experience attacks of pain off and on all day, or even for days or weeks at a time. Then, you may experience no pain for a prolonged period of time. Remission is less common the longer you have trigeminal neuralgia.

People who have experienced severe trigeminal neuralgia have described the pain as:

• Lightning-like or electric-shock-like
• Shooting
• Jabbing
• Like having live wires in your face

Trigeminal neuralgia usually affects just one side of your face. The pain may affect just a portion of one side of your face or spread in a wider pattern. Rarely, trigeminal neuralgia can affect both sides of your face, but not at the same time.

Causes

Branches of the trigeminal nerve CLICK TO ENLARGE

The condition is called trigeminal neuralgia because the painful facial areas are those served by one or more of the three branches of your trigeminal nerve. This large nerve originates deep inside your brain and carries sensation from your face to your brain. The pain of trigeminal neuralgia is due to a disturbance in the function of the trigeminal nerve. Trigeminal neuralgia is also known as tic douloureux.

The cause of the pain usually is due to contact between a normal artery or vein and the trigeminal nerve at the base of your brain. This places pressure on the nerve as it enters your brain and causes the nerve to misfire. Physical nerve damage or stress may be the initial trigger for trigeminal neuralgia.

After the trigeminal nerve leaves your brain and travels through your skull, it divides into three smaller branches, controlling sensation throughout your face:

• The first branch controls sensation in your eye, upper eyelid and forehead.
• The second branch controls sensation in your lower eyelid, cheek, nostril, upper lip and upper gum.
• The third branch controls sensations in your jaw, lower lip, lower gum and some of the muscles you use for chewing.

You may feel pain in the area served by just one branch of the trigeminal nerve, or the pain may affect all branches on one side of your face.

Besides compression from blood vessel contact, other less frequent sources of pain to the trigeminal nerve may include:

• Compression by a tumor
• Multiple sclerosis
• A stroke affecting the lower part of your brain, where the trigeminal nerve enters your central nervous system

A variety of triggers, many subtle, may set off the pain. These triggers may include:

• Shaving
• Stroking your face
• Eating
• Drinking
• Brushing your teeth
• Talking
• Putting on makeup
• Encountering a breeze
• Smiling

Trigeminal neuralgia affects women more often than men. The disorder is more likely to occur in people who are older than 50. About 5 percent of people with trigeminal neuralgia have other family members with the disorder, which suggests a possible genetic cause in some cases.

When to seek medical advice

Some people mistake the pain of trigeminal neuralgia for a toothache or a headache. It's not uncommon for people to believe that their facial pain is dental-related, particularly when the pain seems to stem from the gumline or is located near a tooth.

If you experience facial pain, particularly prolonged pain or pain that hasn't gone away with use of over-the-counter pain relievers, see your dentist or doctor.

Screening and diagnosis

If you go to your dentist, an examination of your mouth can reveal whether a problem with your teeth or gums is causing your pain.

If you go to your doctor, he or she will want to ask about your medical history and have you describe your pain — how severe it is, what part of your face it affects, how long pain lasts and what seems to trigger episodes of pain. You'll also undergo a neurologic examination. During this examination, your doctor examines and touches parts of your face to try to determine exactly where the pain is occurring and — if it appears that you have trigeminal neuralgia — which branches of the trigeminal nerve may be affected.

Your doctor may exclude other possible conditions based on your medical history, the examination, and a magnetic resonance imaging (MRI) scan of your head.

Treatment

Medications are the usual initial treatment for trigeminal neuralgia. Medications are often effective in lessening or blocking the pain signals sent to your brain. A number of drugs are available. If you stop responding to a particular medication or experience too many side effects, switching to another medication may work for you.

Medications

• Carbamazepine (Tegretol, Carbatrol). Carbamazepine, an anticonvulsant drug, is the most common medication that doctors use to treat trigeminal neuralgia. In the early stages of the disease, carbamazepine controls pain for most people. However, the effectiveness of carbamazepine decreases over time. Side effects include dizziness, confusion, sleepiness and nausea.
• Baclofen. Baclofen is a muscle relaxant. Its effectiveness may increase when it's used in combination with carbamazepine or phenytoin. Side effects include confusion, nausea and drowsiness.
• Phenytoin (Dilantin, Phenytek). Phenytoin, another anticonvulsant medication, was the first medication used to treat trigeminal neuralgia. Side effects include gum enlargement, dizziness and drowsiness.
• Oxcarbazepine (Trileptal). Oxcarbazepine is another anticonvulsant medication and is similar to carbamazepine. Side effects include dizziness and double vision.

Doctors may sometimes prescribe other medications, such as lamotrignine (Lamictal) or gabapentin (Neurontin).

Some people with trigeminal neuralgia eventually stop responding to medications, or they experience unpleasant side effects. For those people, surgery, or a combination of surgery and medications, may be an option.

Surgery
The goal of a number of surgical procedures is to either damage or destroy the part of the trigeminal nerve that's the source of your pain. Because the success of these procedures depends on damaging the nerve, facial numbness of varying degree is a common side effect. These procedures involve:

• Alcohol injection. Alcohol injections under the skin of your face, where the branches of the trigeminal nerve leave the bones of your face, may offer temporary pain relief by numbing the areas for weeks or months. Because the pain relief isn't permanent, you may need repeated injections or a different procedure.
• Glycerol injection. This procedure is called percutaneous glycerol rhizotomy (PGR). "Percutaneous" means through the skin. Your doctor inserts a needle through your face and into an opening in the base of your skull. The needle is guided into the trigeminal cistern, a small sac of spinal fluid that surrounds the trigeminal nerve ganglion (the area where the trigeminal nerve divides into three branches) and part of its root. Images are made to confirm that the needle is in the proper location. After confirming the location, your doctor injects a small amount of sterile glycerol. After three or four hours, the glycerol damages the trigeminal nerve and blocks pain signals. Initially, PGR relieves pain in most people. However, some people have a recurrence of pain, and many experience facial numbness or tingling.
• Balloon compression. In a procedure called percutaneous balloon compression of the trigeminal nerve (PBCTN), your doctor inserts a hollow needle through your face and into an opening in the base of your skull. Then, a thin, flexible tube (catheter) with a balloon on the end is threaded through the needle. The balloon is inflated with enough pressure to damage the nerve and block pain signals. PBCTN successfully controls pain in most people, at least for a while. Most people undergoing PBCTN experience facial numbness of varying degrees, and more than half experience nerve damage resulting in a temporary or permanent weakness of the muscles used to chew.
• Electric current. A procedure called percutaneous stereotactic radiofrequency thermal rhizotomy (PSRTR) selectively destroys nerve fibers associated with pain. Your doctor threads a needle through your face and into an opening in your skull. Once in place, an electrode is threaded through the needle until it rests against the nerve root.

  An electric current is passed through the tip of the electrode until it's heated to the desired temperature. The heated tip damages the nerve fibers and creates an area of injury (lesion). If your pain isn't eliminated, your doctor may create additional lesions.

  PSRTR successfully controls pain in most people. Facial numbness is a common side effect of this type of treatment. The pain may return after a few years.

• Microvascular decompression (MVD). A procedure called microvascular decompression (MVD) doesn't damage or destroy part of the trigeminal nerve. Instead, MVD involves relocating or removing blood vessels that are in contact with the trigeminal root and separating the nerve root and blood vessels with a small pad. During MVD, your doctor makes an incision behind one ear. Then, through a small hole in your skull, part of your brain is lifted to expose the trigeminal nerve. If your doctor finds an artery in contact with the nerve root, he or she directs it away from the nerve and places a pad between the nerve and the artery. Doctors usually remove a vein that is found to be compressing the trigeminal nerve.

  MVD can successfully eliminate or reduce pain most of the time, but as with all other surgical procedures for trigeminal neuralgia, pain can recur in some people. While MVD has a high success rate, it also carries risks. There are small chances of decreased hearing, facial weakness, facial numbness, double vision, and even a stroke or death. The risk of facial numbness is less with MVD than with procedures that involve damaging the trigeminal nerve.

• Severing the nerve. A procedure called partial sensory rhizotomy (PSR) involves cutting part of the trigeminal nerve at the base of your brain. Through an incision behind your ear, your doctor makes a quarter-sized hole in your skull to access the nerve. This procedure usually is helpful, but almost always causes facial numbness. And it's possible for pain to recur. If your doctor doesn't find an artery or vein in contact with the trigeminal nerve, he or she won't be able to perform an MVD, and a PSR may be done instead.
• Radiation. Gamma-knife radiosurgery (GKR) involves delivering a focused, high dose of radiation to the root of the trigeminal nerve. The radiation damages the trigeminal nerve and reduces or eliminates the pain. Relief isn't immediate and can take several weeks to begin. GKR is successful in eliminating pain more than half of the time. Sometimes the pain may recur. The procedure is painless and typically is done without anesthesia. Because this procedure is relatively new, the long-term risks of this type of radiation are not yet known.

• Coping skills

  Living with trigeminal neuralgia can be difficult. The disorder may affect your interaction with friends and family, your productivity at work, and the overall quality of your life.

  You may find that talking to a counselor or therapist can help you cope with the effects of trigeminal neuralgia, or you may find encouragement and understanding in a support group. Although support groups aren't for everyone, they can be good sources of information. Group members often know about the latest treatments and tend to share their own experiences. If you're interested, your doctor may be able to recommend a group in your area.