TRIGEMINAL

NEURALGIA IN A
YOUNG FEMALE
PATIENT WITH V1
INVOLEMENT
By: Zoya Morani
Trigeminal Neuralgia
 Case Study
o 17 YEAR OLD WITH PAIN ON LEFT o HEIGH 5’4
FOREHEAD
o WEIGHT145 lb
o SHARP PRICKING PAIN
o CN II – XII GROSSLY INTACK
o SPORADIC
o NO FOCAL DEFICICT
o HAPPENING SEVERAL TIMES
o DTRS ARE NORMAL
o WENT TO CHRIST HOSPITAL ER
o NO ATAXIA ON F-N
o DIAGNOSED WITH TRIGEMINAL
NEURALGIA o TEGRETOL 100 MG PO BID

o LEFT V1 BRANCH INVOLVEMENT

 What is Trigeminal Neuralgia?
o AKA tic douloureux

o chronic pain condition affecting the trigeminal nerve

o Trigeminal nerve carries sensation from your face to your brain

o ("Trigeminal" derives from the Latin word "tria," which means three, and "geminus," which means
twin.)

o fifth of 12 pairs of cranial nerves in the head

o sends branches to the forehead, cheek and lower jaw

o The first branch controls sensation in a person's eye, upper eyelid and forehead.

o The second branch controls sensation in the lower eyelid, cheek, nostril, upper lip and upper gum.

o The third branch controls sensations in the jaw, lower lip, lower gum and some of the muscles
used for chewing.
 What is trigeminal Neuralgia cont.
o mild stimulation of your face may trigger a jolt of excruciating pain (brushing
teeth, applying makeup…etc)

o Described most excruciating pain known to humanity

o typically involves the lower face and jaw

o sometimes affects around the nose and above the eye

o intense, stabbing, electric shock-like pain

o caused by irritation of the trigeminal nerve 

o usually one side of the face

 Prevalence and Incidence
o 150,000 people are diagnosed with trigeminal neuralgia every year

o While the disorder can occur at any age, it is most common in people over the
age of 50

o The National Institute of Neurological Disorders and Stroke(NINDS) notes that

trigeminal neuralgia is more common in women than in men

o evidence that the disorder runs in families, likely as a result of an inherited

blood vessel formation. 

o Hypertension and multiple sclerosis (MS) also are risk factors.

 Symptoms
o Trigeminal neuralgia symptoms may include one or more of these patterns:

o Episodes of severe, shooting or jabbing pain that may feel like an electric shock

o Spontaneous attacks of pain or attacks triggered by things such as touching the face,
chewing, speaking or brushing teeth

o Bouts of pain lasting from a few seconds to several minutes

o Episodes of several attacks lasting days, weeks, months or longer — some people have
periods when they experience no pain

o initially experience short, mild attacks. But trigeminal neuralgia can progress and cause
longer, more-frequent bouts of searing pain
 Symptoms Cont.
o Constant aching, burning feeling that may occur before it evolves into the
spasm-like pain of trigeminal neuralgia

o Pain in areas supplied by the trigeminal nerve, including the cheek, jaw,
teeth, gums, lips, or less often the eye and forehead

o Pain affecting one side of the face at a time, though may rarely affect both
sides of the face

o Pain focused in one spot or spread in a wider pattern

o Attacks that become more frequent and intense over time

 Triggers
o Attacks of trigeminal neuralgia o Blowing the nose
may be triggered by the
o Drinking hot or cold
following:
beverages
o Touching the skin lightly
o Encountering a light breeze
o Washing
o Applying makeup
o Shaving
o Smiling
o Brushing teeth
o Talking
 Causes
o In trigeminal neuralgia the trigeminal nerve's function is disrupted

o problem is usually contact between a normal blood vessel — in this case, an artery or a vein —
and the trigeminal nerve at the base of your brain. This contact puts pressure on the nerve and
causes it to malfunction.

o Trigeminal neuralgia can occur as a result of aging, or it can be related to multiple sclerosis or
a similar disorder that damages the myelin sheath protecting certain nerves. Trigeminal
neuralgia can also be caused by a tumor compressing the trigeminal nerve.

o Some people may experience trigeminal neuralgia due to a brain lesion or other abnormalities.
In other cases, surgical injuries, stroke or facial trauma may be responsible for trigeminal
neuralgia.

o Development of trigeminal neuralgia in a young adult suggests the possibility of MS.

 Causes Cont.
o Most patients report that their pain begins spontaneously and seemingly out of nowhere.

o Pain can follow a car accident, a blow to the face or dental surgery.

o Most physicians and dentists do not believe that dental work can cause trigeminal neuralgia.

o In these cases, it is more likely that the disorder was already developing, and the dental
work caused the initial symptoms to be triggered coincidentally.

o Pain often is first experienced along the upper or lower jaw, so many patients assume they
have a dental abscess.

o Some patients see their dentists and actually have a root canal performed, which inevitably
brings no relief. When the pain persists, patients realize the problem is not dental-related.
 Typical vs Atypical pain
o The pain of trigeminal neuralgia is defined as either Type I (sometimes also referred
to as “classic”) or Type II (may also be called “atypical”) 

o classic pain - there are definite periods of remission.

o pain is intensely sharp, throbbing and shock-like and usually triggered by touching
an area of the skin or by specific activities.

o Type II pain often is present as a constant, burning sensation affecting a more

widespread area of the face

o With atypical trigeminal neuralgia, there may not be a remission period, and
symptoms are usually more difficult to treat.
 Characteristic of T.N. Pain
o Trigeminal neuralgia tends to run in cycles

o Patients often suffer long stretches of frequent attacks followed by weeks, months or even
years of little or no pain

o The usual pattern, however, is for the attacks to intensify over time with shorter pain-free
periods.

o Some patients suffer less than one attack a day, while others experience a dozen or more
every hour

o The pain typically begins with a sensation of electrical shocks that culminates in an
excruciating stabbing pain within less than 20 seconds

o pain often leaves patients with uncontrollable facial twitching, which is why the disorder is
also known as tic douloureux.
 Differential Diagnosis
o The symptoms of several pain disorders are similar to those of trigeminal neuralgia. 

o Temporal tendinitis involves cheek pain and tooth sensitivity, as well as headaches

and neck and shoulder pain. This condition is called a "migraine mimic" because its
symptoms are similar to those of a migraine.

o Ernest syndrome is an injury of the styomandubular ligament, which connects the

base of the skull with the lower jaw, producing pain in areas of the face, head and
neck. 

o Occipital neuralgia involves pain in the front and back of the head that sometimes
extends into the facial region.
 Diagnosis
o If you experience facial pain, particularly prolonged or recurring pain or pain
unrelieved by over-the-counter pain relievers, see your doctor.

o Magnetic resonance imaging (MRI) can detect if a tumor or MS is irritating

the trigeminal nerve. However, unless a tumor or MS is the cause, imaging
of the brain will seldom reveal the precise reason why the nerve is being
irritated. The vessel next to the nerve root is difficult to see even on a high-
quality MRI. Tests can help rule out other causes of facial disorders.

o Trigeminal neuralgia usually is diagnosed based on the description of the

symptoms provided by the patient.
 Treatment
o There are several effective ways to alleviate the pain, including a variety of medications.

o Because of the variety of treatment options available, having trigeminal neuralgia doesn't necessarily mean you're doomed
to a life of pain. Doctors usually can effectively manage trigeminal neuralgia with medications, injections or surgery.

o Carbamazepine, an anticonvulsant drug, is the most common medication that doctors use to treat trigeminal neuralgia. In
the early stages of the disease, carbamazepine controls pain for most people. When a patient shows no relief from this
medication, a physician has cause to doubt whether trigeminal neuralgia is present. However, the effectiveness of
carbamazepine decreases over time. Possible side effects include agranulocytosis, dizziness, double vision, drowsiness and 
nausea.

o Baclofen is a muscle relaxant. Its effectiveness may increase when it is used with either carbamazepine or phenytoin.
Possible side effects include confusion, depression and drowsiness.

o Phenytoin, an anticonvulsant medication, was the first medication used to treat trigeminal neuralgia. Possible side effects
include gum overgrowth, balance disturbances and drowsiness.

o Oxcarbazepine, a newer medication, has been used more recently as the first line of treatment. It is structurally related to
carbamazepine and may be preferred because it generally has fewer side effects. Possible side effects include dizziness and
double vision.
o Other medications include gabapentin, clonazepam, sodium valporate, lamotrigine and topiramate.

o There are drawbacks to these medications other than side effects. Some patients may need
relatively high doses to alleviate the pain, and the side effects can become more pronounced at
higher doses.

o Anticonvulsant drugs may lose their effectiveness over time. Some patients may need a higher dose
to reduce the pain or a second anticonvulsant, which can lead to adverse drug reactions. Many of
these drugs can have a toxic effect on some patients, particularly people with a history of 
bone marrow suppression and kidney and liver toxicity. These patients must have their blood
monitored to ensure their safety.

o Although trigeminal neuralgia cannot always be cured, there are treatments available to alleviate
the debilitating pain. Normally, anticonvulsive medications are the first treatment choice.

o Surgery can be an effective option for those who become unresponsive to medications or for those
who suffer serious side effects from the medications.
 Non-medical & Surgical Treatments
o If medications have proven ineffective in treating trigeminal neuralgia, there are several surgical procedures that
may help control the pain.

o Surgical treatment is divided into two categories: 

o 1) open cranial surgery or 2) lesioning procedures.

o open surgery is performed for patients found to have pressure on the trigeminal nerve from a nearby blood vessel,
which can be diagnosed with imaging of the brain, such as a special MRI.

o This surgery is thought to take away the underlying problem causing the trigeminal neuralgia, and is thus often
the treatment of choice for most patients.

o lesioning procedures include interventions that injure the trigeminal nerve on purpose, in order to prevent the
nerve from delivering pain to the face.

o The effects of lesioning are often short-lived, lasting months to years, and results in numbness to the face.
Lesioning procedures are often considered for the following patients: those who have recurrent pain after open
surgery, those without evidence of a blood vessel pushing on the nerve, and those are poor surgical candidates. 
 References
o https://www.practicalpainmanagement.com/pain/maxillofacial/trigeminal-neuralgia-current
-diagnosis-treatment-options

o https://www.everydayhealth.com/multiple-sclerosis/what-trigeminal-neuralgia/

o https://www.mayoclinic.org/diseases-conditions/trigeminal-neuralgia/symptoms-causes/sy
c-20353344#:~:text=Trigeminal%20neuralgia%20is%20a%20chronic,a%20jolt%20of%20ex
cruciating%20pain
.

o https://www.webmd.com/pain-management/guide/trigeminal-neuralgia#1

o https://www.aans.org/Patients/Neurosurgical-Conditions-and-Treatments/Trigeminal-Neura
lgia#:~:text=Percutaneous%20stereotactic%20rhizotomy%20treats%20trigeminal,cheek%
20into%20the%20trigeminal%20nerve
.