For the past three weeks, Eliza Fitter, aged 65, has been experiencing excruciating painful attacks on the right side of her face several times each day. The pain is often triggered while eating, drinking, and brushing her teeth. Eliza presents to her physician’s office where she is diagnosed with trigeminal neuralgia.
Trigeminal neuralgia, also known as tic douloureux, is a neuropathic pain condition that involves the trigeminal or fifth cranial nerve, which supplies sensory information to the skin and mucous membranes of the face, as well as motor information for the muscles of mastication. And because of that, pain can often be triggered by chewing, brushing the teeth, shaving, or even just smiling!
Now, the exact cause of trigeminal neuralgia is not well known, but it’s thought to be associated with vascular compression of the trigeminal nerve root. Some risk factors include female sex, increased age, and family history, as well as disorders like hypertension, multiple sclerosis, a brainstem tumor, an aneurysm, or a previous stroke.
Now, the main symptom of trigeminal neuralgia is a sudden, excruciating, sharp, pain, similar to an electric shock. Typically, the pain is unilateral and involves the lower face, from the corner of the mouth to the jaw, although in some clients it can also involve the area around the nose, cheek, and above the eye. The pain occurs in paroxysmal attacks that generally last from a few seconds up to 2 minutes, and may recur after just minutes, as often as a hundred times per day! As a consequence,trigeminal neuralgia can be incapacitating and interfere with the client’s daily activities like eating, sleeping, or communicating. In the long term, the pain could be so unbearable that it may lead to mental health disorders like depression, and some clients may even consider suicide.
Diagnosis of trigeminal neuralgia mainly relies on history, since neurological examination is typically normal. There’s no specific laboratory or imaging test, but sometimes they can be done to rule out other disorders, such as rheumatic conditions, tumors, or aneurysms.
Treatment is aimed at relieving the pain and improving the client’s quality of life. The medications of choice to treat trigeminal neuralgia include antiseizure medications like carbamazepine; while alternative options include phenytoin, gabapentin, and baclofen. If none of these medications are effective in relieving the pain, a peripheral nerve block can be done, where an anesthetic is injected to block sensation from the trigeminal nerve, giving temporary pain relief. If all treatment options fail, the client may consider surgical treatment, which includes procedures like microvascular decompression, where the trigeminal nerve is separated from nearby arteries that may be compressing it; percutaneous rhizotomy, where one or more branches of the trigeminal nerve is cut to remove all facial sensation; or gamma knife radiosurgery to deliver radiation at the proximal trigeminal root, disrupting the pain signal to the brain.
Okay, let’s get back and assess your client Eliza. You enter her room, introduce yourself, wash your hands, and confirm her identity. You ask Eliza how she is feeling today, and she states she has been experiencing stabbing pain shooting from the corner of her mouth to the angle of the jaw. She describes the pain as severe and episodic, starting with what feels like a sensation of electrical shocks which crescendos in less than 20 seconds to excruciating discomfort felt deep in her face. On a pain scale of 0 to 10, she rates her pain a 10 during an episode. Eliza states the pain is excruciating and incapacitating during each episode but does not experience any pain in-between episodes. She explains she is reluctant to eat, drink, or brush her teeth because these trigger the painful episodes.