Chronic Pain Management (Part 1): Dealing with Excruciating Pain- Trigeminal Neuralgia

Very rarely, yes. Most of the time trigeminal neuralgia is on one side of the face. On the MRIs, we may find compression on both sides, but they may not have symptoms on both sides. If someone has symptoms on both sides, we have to look at a different diagnosis.

Trigeminal neuralgia itself is caused by compression, as the vessel rubs against the nerve and that damages the nerve as it rubs more and more. It is not a blood vessel problem but rather the compression and rubbing on the nerve that causes the damage.

There may be many causes of failure. It could be surgical factors, the nerve and blood vessels compressed, and occasionally people may miss the compression. So these are the technical factors in any kind of procedure. Occasionally the pain reoccurs even though it has been decompressed correctly. Not everything is known about trigeminal neuralgia, and there are other factors that may cause the pain to recur as well, despite adequate decompression.

Usually yes. We can discuss surgical treatment, but we would not want to proceed before having an MRI scan.

Essentially immediately after surgery, up to 90% patients feel that their pain is better and then we stop them on whatever drugs they are on for the next few weeks. There is a chance of recurrence with time the symptoms may come back and about 20% of patients do find that there is a recurrence in the next 5 years.

Rhizotomy is where we use a needle to go through the cheek to reach the nerve near the base of the brain. It's quite a long needle. There is no specific contraindication per se, things like patients being on anticoagulant medication being the key one. I think the main thing in terms of choosing rhizotomy versus something else is the symptom duration and how long the patient expects to be controlled like I said rhizotomy does not last so long and there is a higher failure rate.

Gabapentin is another medication commonly used for pain of nerve origin, so a neuropathic pain. It can be tried as an alternative; some patients may need a combination of both carbamazepine plus Gabapentin for it to work. Especially if patients have a lot of side effects from carbamazepine where they may need to deal with dizziness or sleepiness.

The nerve most commonly affected is the fifth cranial nerve, aka the trigeminal nerve, while the vessel itself is the superior cerebellar artery.

It is an acute severe pain and the most classic way it feels is a severe stabbing electric-like pain. Not everyone has the classic form though.

No. It is different. Pain on the face may be from various reasons and in this case, it’s a specific cause for this that we can treat. The underlying cause is different, thus treatment is different as well.