Trigeminal Neuralgia

Clinical Features

• Paroxysmal Pain Attacks: Episodes of severe, electric-shock-like pain lasting from seconds to minutes.
• Pain Distribution:
  • V1 (Ophthalmic branch): Pain in the forehead and eye.
  • V2 (Maxillary branch): Pain in the cheek and upper lip.
  • V3 (Mandibular branch): Pain in the ear, jaw, lower lip, teeth, and mandible.
• Pain Characteristics:
  • Sharp, stabbing, or burning sensations.
  • Abnormal sensations such as crawling of worms.
• Attack Duration: Typically 2-20 seconds, occurring in paroxysms lasting 2-4 minutes.

Precipitating Factors

• Exposure to cold wind.
• Activities such as face washing, chewing, eating cold food, shaving, or touching the face.

Causes

1. Idiopathic:

   • Caused by compression of the trigeminal nerve near its exit from the brainstem by an aberrant loop of artery or vein.

2. Secondary Causes:

   • Tumors or demyelinating plaques from multiple sclerosis causing lesions in the trigeminal nerve root.

Diagnosis

• Clinical Diagnosis:
  • Pain is typically unilateral, except in cases associated with multiple sclerosis where it may be bilateral.
  • Characterized by paroxysms of intense pain.
• MRI (Fiesta View):
  • Identifies compression of the trigeminal nerve by vessels or tumors.
  • Sometimes no compression is evident.

Management at RS Clinic

Medical Management

1. First-Line Treatment:

   • Carbamazepine: The drug of choice, starting at 100 mg twice daily, gradually increasing to a maximum of 800 mg per day. Beyond this dose, side effects outweigh benefits.

2. Second-Line Drugs:

   • Gabapentin, Baclofen, and Lamotrigine: Often used to minimize the dose and side effects of Carbamazepine.

Surgical Procedures

1. Microvascular Decompression:

   • Major brain surgery under general anesthesia.
   • Used when vascular compression of the trigeminal ganglion is visible.
   • Risks: Blood loss, vision loss, paralysis, or incomplete pain relief.

2. Stereotactic Radiosurgery:

   • Non-invasive procedure using a gamma knife or linear accelerator to target the trigeminal nerve.

Advanced Non-Surgical Treatments at RS Clinic

1. Glycerol Rhizotomy:

   • Chemical neurolysis using glycerol. Rarely used due to risks of neuritis.

2. Balloon Compression:

   • Percutaneous procedure to compress the trigeminal nerve using an inflated balloon. Fewer side effects but lower efficacy.

3. Radiofrequency Ablation (RFA):

   • A minimally invasive, outpatient procedure performed by our experts at RS Clinic.
   • A small needle is inserted into the foramen ovale under fluoroscopic guidance, and radiofrequency waves are used to target and ablate the affected nerve.

   Advantages of RFA at RS Clinic:

   • Immediate and effective pain relief.
   • No major complications or prolonged recovery time.
   • Procedure can be repeated if necessary.
   • Over 98% success rate in providing long-term relief.