Trigeminal Neuralgia – Causes, Treatments & Surgery | MedStar Health

Trigeminal neuralgia is one of the most painful neurological conditions.

It is characterized by sudden, electric shock-like pain on one side of the face. The location of the pain is determined by the branches of the trigeminal nerve and can involve the forehead and corner of the eye, cheek, and corner of the nose, lower jaw, and corner of the mouth. The pain can also occur in a combination of these three locations.

The shocks typically last a few seconds, and can occur as rarely as once a day, or as often as many times an hour.

Some activities and environmental stimuli can trigger the pain, including:

  • Chewing
  • Talking
  • Brushing teeth
  • Cold temperature
  • Windy conditions

Causes of trigeminal neuralgia

Although the exact cause of trigeminal neuralgia is unknown, and it may in fact be due to multiple causes occurring simultaneously, we do know that one of the major culprits is a normal blood vessel coursing in an abnormal way and pressing on the trigeminal nerve.

The pulsation of the vessel beating on the nerve over many years causes the nerve to function abnormally.

How this process generates the painful sensation is ill-defined to this day. However, if surgery is performed to move the blood vessel away from the nerve, the symptoms usually improve significantly.

This is the basis of the surgical treatment called “microvascular decompression.”

Diagnosis of trigeminal neuralgia

In order to diagnose this problem, your MedStar Health physician will:

  • Obtain a medical history from you, including your symptoms, their timing, frequency, location, and triggers 

  • Perform a physical exam to check your facial sensation, amongst other functions

  • Order diagnostic tests, such as an MRI. The MRI of the base of the skull is particularly useful to tailor specific treatments for this condition. When formatted to look at the nerves at the base of the brain (CISS, FIESTA, Propeller sequences), the information can tell your doctor which option may be best

Trigeminal neuralgia treatments

After the initial diagnosis is made, your MedStar Health physician will discuss treatment options with you, including medication and surgery.

Medications for trigeminal neuralgia

Initial treatment includes medication to provide pain relief. Common medications used at this stage include:

  • Tegretol
  • Neurontin
  • Lyrica
  • Trileptal
  • Lamictal

For most patients, one medication or a combination of them will control the pain sufficiently. But if trials of multiple medications fail, surgical options should be considered.

Failure of medication can either be due to inability of the medications to control the pain sufficiently, or because the patient is unable to tolerate the side-effects of the medicines at doses that control the pain. Typical side effects for this type of medication can include:

  • Drowsiness
  • Nausea
  • Inability to concentrate
  • Loss of balance

Surgery for trigeminal neuralgia

If medications are insufficient to control the pain, or if side-effects make them intolerable, then surgery may the answer.

The neurosurgeons at MedStar Health are among the best in their field, and work in teams of specialists to provide the best possible patient care.

The following surgical approaches provide options for a tailored treatment plan for trigeminal neuralgia, ranging from open surgery (craniotomy) to non-invasive (CyberKnife). These options also vary in efficacy and duration of effect.

  • Microvascular decompression

    As the name implies, this operation is designed to move the blood vessel that is pressing on the trigeminal nerve.

    With this microsurgical technique, the vessel is padded away from the nerve with a Teflon cushion, so that the nerve will no longer be harmed by the pulsation in the blood vessel. It is by far the most effective surgical treatment, with long-lasting pain-relieving results.  It is also the only surgical option that is designed to preserve the trigeminal nerve and its function.

    Under the expert hands of our surgeons, immediate pain relief is achieved in over 80% of patients who have undergone this operation. Only a minority had recurrent pain many years after the operation.

  • CyberKnife® radiosurgery

    With CyberKnife, radiation beams are delivered to the trigeminal nerve with pin-point accuracy in order to dull the pain. There is no cutting, blood loss, or hospital stay. The entire treatment is invisible, painless, and lasts only about 45 minutes. Most patient experience reduction of the face pain within several days to weeks, but some people do experience return of their pain, albeit at lower levels, several years later. The CyberKnife option is best suited for patients whose age or medical conditions make open-surgery dangerous to them.

    At MedStar Health, our physicians were the first on the East Coast to adopt CyberKnife and remain among the most experienced users in the world. We have been using CyberKnife to treat trigeminal neuralgia for more than a decade; we also include a comprehensive team approach in order to provide the best patient care.

    Learn more about CyberKnife at MedStar Health.

  • Percutaneous balloon rhizotomy

    In this technique, performed under general anesthesia, a needle is inserted near the corner of the mouth. Under X-ray guidance, the surgeon then advances the needle through the base of the skull to the root of the trigeminal nerve. Once that target is reached, a balloon is inflated and the pressure of the balloon dulls the trigeminal nerve, making the painful sensation disappear. 

    Most patients experience reduction of facial pain upon waking from anesthesia, so the effect is immediate. The recurrence of pain is variable and highly dependent on the circumstances of the individual patient.

    This is an outpatient procedure with no overnight hospital stay required.

  • Percutaneous radiofrequency rhizotomy

    This procedure is very similar to the balloon rhizotomy except that it is performed with the patient under sedation and not general anesthesia.

    The needle is once again advanced to the root of the trigeminal nerve. When the target is reached, the sedation is lightened, so that the patient is awake enough to cooperate with intraoperative testing. Mini pulses of electricity are sent through the needle to mimic the painful shocks with this condition. When the test pulse is able to simulate the patient’s pain in the exact distribution as their trigeminal neuralgia, radiofrequency—or heat—is sent through a wire in the needle to dull the trigeminal nerve.

    There is no hospital stay after the outpatient procedure, and most patients experience pain relief when they leave the hospital.

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Dr Anette Virta-Paras poses in front of a set of brain scans at MedStar Health.

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Treating facial pain with functional neurosurgery