(tic douloureax): paraoxysmal lacinating pain that persists for a few seconds, usually brought on by touch to the involved area, confined to one of the branches of the trigeminal nerve on one side of the face, without any other neurological abnormality.

Annual incidence 4/100,000, males slightly more often affected

no association with herpes virus infections, often will attain spontaneous remission; with pain free periods lasting weeks-months.

2% of patients with multiple sclerosis (MS) have trigeminal neuralgia and 18% of patients with bilateral symptoms of trigeminal neuralgia have M.S..

Average age: 63, very seldom seen in patients under 50. Usually on the right side (60%), less often on the left (39%) and seldom bilateral (1%).

Upper face involved in only 2% of cases, middle face 20% of the time and the lower face 17% of the time. Upper and middle face involved in 14%, mid and lower face involved in 42% and all three areas in 5%.

Cause of Trigeminal Neuralgia: usually due to compression of the trigeminal nerve by a blood vessel, occasionally due to pressure from a tumor (<0.8%), and rarely from M.S..

Other causes of similar facial pain: Shingles (varicella zoster virus), but this pain is continuous and there is usually a rash of vesicles over the involved area which is usually the upper part of the face and often the eye.

Dental disease

Orbital disease

Temporal arteritis: causes pain over the side of the head, with tenderness of the involved temporal artery.

Brain tumor: usually presents with sensory of numbness or tingling sensation or constant pain.

Diagnosis: based on assessment by a physician familiar with trigeminal neuralgia as there is no specific test available to prove the diagnosis although some tests may be carried out to exclude other possible causes.

Treatment for Trigeminal Neuralgia

Medical Therapy: carbamazepine (Tegretol). Provides complete or nearly complete relief in 69% of patients

baclofen (Lioresal) 2^nd drug of choice

pimozide (Orap) less useful drug than above medications.

Others include phenytoin (Dilantin), capsaicin (Zostrix), clonazepam, and amitryptiline (Elavil).

Surgical Treatment

Reserved for patients who are not controlled with medications or who are intolerant of the medications used to treat trigeminal neuralgia.

Different surgical options:

1. peripheral trigeminal nerve procedures to block the branch causing the pain or the trigger site that brings on the pain. These include removing the nerve branch or injecting it with a medication that destroys the nerve.

1. 2. blocking the nerve more centrally with an injection of medication into the ganglion (location of the nerve cells that transmit the painful sensation) or in a similar fashion heating up of the ganglion to destroy the transmission of these impulses to the brain.

1. 3. formal surgery on the blood vessel etc. that is causing compression of the trigeminal nerve inside the head. This is typically reserved for patients who are<65 years of age, without significant medical or surgical risk factors who have not responded to the above mentioned procedures. Probably the most effective treatment at the hands of an experienced surgeon (>70% pain free at 10 years) but also the most risky procedure with a mortality rate of ~ 1% and major neurological injury including stroke in 1-10%.

The above surgical procedures in Saskatchewan are available in Regina and Saskatoon. For further information see your family physician.

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