Tuesday, December 10, 2002 - 12:43:58 AM MST
Dear Dr. Douma:
I have been plagued with trigeminal neuralgia for years and pain medications don't help. Is there anything new?
-- M.T., Pendleton, Ore.
Trigeminal neuralgia is also called tic douloureux (pronounced "tick do-la-rue'). It's an abnormal functioning of the trigeminal nerve, which carries electrical signals between the brain and part of the face.
Each side of the face has its own trigeminal nerve and, almost always, only one nerve and therefore one side of the face is affected.
This condition is characterized by episodes of sudden, severe, stabbing pain on one side of the face that lasts from several seconds to several minutes. The pain is often triggered by movements such as chewing, talking, touch or even drafts.
The condition might spontaneously go away for many months. However, the pain often becomes more frequent. with time between episodes becoming shorter. Later, a dull ache might persist between episodes of pain.
Damage to the nerve from trauma can cause the symptoms of trigeminal neuralgia. The condition is also a frequent problem for people with multiple sclerosis. On rare occasions, it might result from a tumor.
Also, more recently, it was found that another common cause is an abnormal blood vessel pushing on the nerve. In such cases, an operation, called a neurovascular decompression, can separate the blood vessel from the nerve and relieve the pain.
Because there are a number of treatment options, it's important to understand the benefits, risks and costs of each before deciding which way you want to go. Typical pain relievers aren't usually helpful because the episodes of pain come on so quickly and last only a short time.
Anti-seizure medications such as carbamazepine have been the standard drug treatment of trigeminal neuralgia. Newer drugs such as lamotrigine have been shown to be effective as well.
If these drugs are not effective or not tolerated well, phenytoin might also help either alone or in combination. Also, some promising new drugs are on the horizon include pimozide, tizanidine and topical capsaicin.
Neurotonin (gabapentin) has been shown to demonstrate an analgesic effect for the treatment of some forms of nerve pain and might work on trigeminal neuralgia as well.
Since several drugs appear to be effective, ask your doctor how much better a more expensive drug is than a less expensive one.
The trigeminal nerve can be cut or destroyed by injecting a chemical into it, or by using radio frequencies or gamma rays. Radio frequencies or gamma radiosurgery are noninvasive and are successful 60 percent to 80 percent of the time.
About third of those getting these "surgical' procedures will develop some numbness in the face, but most of the time it will be a minor problem.
If you decide to go ahead with the surgery, be sure to ask the neurosurgeon for his or her training and success rate. Second opinions are advisable for many surgeries, and can be valuable when a number of treatment options are available and when new treatments are under investigation.
Recent advances in developing 3D images using MRI machines have been shown to provide a good view of the trigeminal nerve and any surrounding tissue that might be putting pressure on it. But it will be years before this is perfected and broadly available.
Update on mastectomy: Having a mastectomy causes a great deal of turmoil and emotional pain for many women. And the longer she goes without breast reconstruction, the more difficult the situation becomes.
A recent study has shown that a woman who is getting chemotherapy doesn't need to wait nearly as long as thought.
In a paper presented at the Scientific meeting of the American Society of Plastic Surgeons, immediate reconstruction did not delay post-operative chemotherapy, prolong recovery or mask the recurrence of breast cancer.
As you would expect, the women in the study were pleased with their
experience and had fewer emotional problems.
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