Trigeminal Neuralgia Treatments

Treatment options for those with Trigemenial Nueralgia (TN) include medication, nerve blocks, complementary approaches or various surgical procedures.  Below you will find more information on each treatment option.

Medication

• Anticonvulsant medicines are used to block nerve firing and are generally effective in treatment of TN.
• Tricyclic antidepressants are used to treat pain described as constant, burning or aching.
• Typical analgesics and opioids are not usually helpful in treating the sharp, recurring pain caused by TN.
• If medication fails to relieve pain or produces intolerable side effects such as excess fatigue, surgical treatment may be recommended.

Nerve Blocks

A nerve block is an injection that temporarily inhibits a nerve’s ability to transmit pain signals:

• Local Anesthetics – A local anesthetic is injected into the trigger area and stops the pain for approximately the time period that the drug is active. This is not a means of achieving long term relief.
• Alcohol Block – Alcohol is injected into the peripheral branches of the trigeminal nerve resulting in pain relief that lasts approximately one year. Repeated blocks tend to be less effective.

Complementary Techniques

Some patients choose to manage TN using complementary techniques, usually in combination with drug treatment. These therapies have not been studied as thoroughly as medication or surgical procedures for TN, but some people have benefited from them. These therapies offer varying degrees of success. Be sure to consult with your doctor before trying out any new complementary therapies.

• Acupuncture
• Biofeedback
• Vitamin therapy
• Nutritional therapy
• Electrical nerve stimulation

Surgery

Surgical procedures that are used to treat TN can be classified as either destructive or non-destructive.

Non-destructive treatments attempt to eliminate the underlying cause of trigeminal neuralgia without causing injury or damage to the trigeminal nerve. The most common treatment within this category is microvascular decompression (MVD). During MVD, physicians move any compressing blood vessels and pad the nerve with a small piece of Teflon. MVD is the only non-destructive procedure that reliably relieves TN symptoms.

Destructive treatments attempt to control pain by destroying or damaging sections of the trigeminal nerve. Their effects are often temporary so, in some cases, they must be repeated every few years in order to maintain pain relief. With any destructive treatment, the rate of certain side effects (such as numbness or a loss of sensation) is higher than the same rate in non-destructive treatments. Examples of destructive treatments include:

• Stereotactic Radiosurgery (Gamma Knife)
• Retrogasserian Neurotomy
• Peripheral Neurectomy
• Trigeminal Tractotomy
• Radiofrequency Thermal Lesioning
• Glycerol Injection
• Balloon compression

Surgery: Balloon Compression

During balloon compression, a tube called a cannula is inserted through the cheek and guided to the position where one branch of the trigeminal nerves passes through the base of the skull. A soft catheter with a balloon tip is threaded through the cannula and the balloon is inflated to squeeze part of the nerve against the hard edge of the dura mater (a thick covering that surrounds the brain). The pressure created by this compression damages the trigeminal nerve and blocks pain signals. Most patients undergoing the procedure report some facial numbness. Some experience temporary or permanent muscle weakness when they try to chew.

Balloon compression appears to be particularly advantageous for patients with V-1 (upper region) pain who are not good candidates for microvascular decompression. Although it is generally an outpatient procedure, some patients may be kept in the hospital overnight.

Surgery: Glycerol Injection

Glycerol injection is usually an outpatient procedure in which the patient is sedated intravenously. A thin needle is passed through the cheek, next to the mouth, and guided through the opening in the base of the skull to where all three branches of the trigeminal nerve come together. The physician then injects a small amount of sterile glycerol that damages the trigeminal nerve fibers and blocks pain signals. The procedure is ideal for patients with contralateral pain, trigeminal motor weakness, and temporo-mandibular joint dysfunction. It is also appropriate for patients who have V-1 (upper region) pain, pain in their entire face, and patients who are not viable candidates for more invasive surgical procedures.

Glycerol injections are associated with a high recurrence rate; it is likely that the patient will need the procedure to be repeated in the future. Subsequent injections have a higher risk of failure and are more likely to produce adverse side effects.

Surgery: Radiofrequency Thermal Lesioning

During this procedure, a patient is sedated while a hollow needle is inserted through the face and guided to the trigeminal nerve. Once the needle is positioned, the patient is awakened. The surgeon inserts an electrode through the needle and uses it to send a mild electric current. This causes a tingling sensation in the patient’s face. The patient is asked when and where the tingling occurs. The surgeon will use this information to determine which part of the nerve is involved in the sensation of pain.

After the patient is sedated for a second time, the electrode is gradually heated until it damages the identified nerve region, creating an injury (lesion) that disrupts the nerve’s ability to transmit pain signals. The electrode and needle are removed and the patient is awakened. If the patient’s pain isn’t eliminated, the doctor may want to create additional lesions.

Surgery: Stereotactic Radiosurgery

Stereotactic radiosurgery (gamma knife, cyber knife) uses computer imaging to direct highly focused beams of radiation at the site where the trigeminal nerve exits the brainstem. This causes the formation of a lesion (injury) that disrupts the nerve’s ability to transmit pain signals to the brain. Patients usually leave the hospital the same day or the day following treatment. They do not typically experience relief from their pain for several weeks or even months after surgery.

Stereotatic radiosurgery generally seems to be the most appropriate procedure for elderly patients and those in poor medical health who cannot safely undergo more invasive surgical procedures. It may not be the ideal treatment for patients with V-1 pain (pain located in the upper division near the forehead) or patients with pain distributed over all three trigeminal nerve divisions (upper, middle, and lower).

Surgery: Mircovascular Decompression (MVD)

MVD is the most invasive of all surgeries for TN, but it also offers the best opportunity for permanent relief. During the procedure, a physician makes an incision behind the ear. Using a microscope, the physician moves any arteries that are compressing the trigeminal nerve and places a pad between the nerve and the arteries. Patients recuperate in the hospital for several days afterward.

If no blood vessel is found during microvascular decompression, a “neurectomy” might be performed, which involves cutting part of the trigeminal nerve. This might cause permanent numbness to the area of the face that was associated with that nerve segment. However, after the operation is performed, it is possible that the nerve will grow back and sensation to the associated facial area will return.

No surgery is without risks. Complications of any surgery include bleeding, infection, blood clots, and reactions to anesthesia. Complications specifically related to a craniotomy (the removal of part of the skull to expose the brain) include stroke, seizures, venous sinus occlusion, swelling of the brain, and cerebrospinal fluid leakage. The most common complication of MVD is nerve damage, which could possibly result in hearing loss, double vision, facial numbness or paralysis, hoarseness, difficulty swallowing (dysphagia), and unsteady gait.

Overall, MVD is highly successful at treating trigeminal neuralgia. The procedure has been reported to be 95 percent effective with a relatively low risk of pain recurrence (20 percent within 10 years). The major advantage of this procedure is that it causes little or no facial numbness compared to destructive surgical approaches. Although MVD is very effective, because it is a more invasive procedure it is best suited for healthy patients.