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School of Medicine
Trigeminal Neuralgia Treatments
There Is Hope for Treating Trigeminal Neuralgia Pain
If you or someone you love has trigeminal neuralgia, the one thing you should not do is feel alone or hopeless. Despite the uncertainty of what causes trigeminal neuralgia, we do know a lot about treating this painful condition.
In treating many people over many years, we have found that there seems to be an approach for everyone. Therapies may include medicines, outpatient procedures, brain surgery or radiation. The first thing you should do is learn about your options and rest assured your clinician will work with you to select the treatment option that is most appropriate for your situation.
No one should accept trigeminal neuralgia pain as untreatable.
Many people who suffer from trigeminal neuralgia successfully treat this condition for many years with medication. Trigeminal neuralgia drug therapy uses some of the same medicines used for seizures.
If you think of trigeminal neuralgia as an electrical current through your face, just as electrical currents through the brain can cause seizures, it makes sense that some of the same medicines works for both. Here are some medications known to work for controlling trigeminal neuralgia:
- Carbamazepine is the gold standard. It treats the condition very well, but can have undesirable side effects such as drowsiness, unsteadiness, difficulty with coordination and memory, slurred speech and some difficulty with thingking or remembering. You will also need to get regular blood tests because your white blood cell count, platelets and liver functions must be checked. However, it works better on the pain than most other drugs and has been used safely by millions of people for seizures. Most patients start out on low doses, gradually increasing the dose under clinical supervision until they achieve the best pain relief with the least number of side effects.
- Gabapentin is also used. It does not require regular blood work.
- A newer addition to the medication options is a carbamazepine-type drug that may have fewer side effects, but still requires some monitoring by your doctor since it can affect your blood sodium.
Many other medications can help. Your neurologist or primary care physician can help you select and use the best drug in the most appropriate dosage.
If Medication Doesn’t Work
If medication no longer controls your trigiminal neuralgia pain or if the side effects are intolerable, there are several procedures to consider. It helps to learn about these options before you are in urgent need of relief so you and your doctor can make a good choice. Your general medical condition, age, pain level and the availability of the procedure will all factor in to this decision.
Most trigeminal neuralgia patients are suitable candidates for the procedure, and the team at Johns Hopkins has performed rhizotomies safely on patients as old as 100 years of age.
There are several types of rhizotomies, but they all involve destroying the fibers within the trigeminal nerve that are carrying pain signals. These are outpatient procedures performed under general anesthesia in the operating room where your surgeon and team can conduct all the customary monitoring of your vital signs.
The rhizotomy itself takes only a few minutes. Afterward, you will spend about two to three hours in the recovery room. Depending on how you handle the anesthesia, you may be able to return to work on the first or second postoperative day.
While you are asleep under anesthesia and sitting upright, the surgeon places a long needle into the cheek just adjacent to the mouth on the side where the pain occurs. The needle is carefully advanced under x-ray guidance to the level of the foramen ovale, a small hole at the base of the skull just behind the eye. The ganglion of the trigeminal nerve is located just behind this opening.
Once the needle is in place, a small amount (0.4 cc) of clear, colorless chemical is injected into the ganglion of the nerve. The chemical will destroy nerve fibers and particularly the pain fibers over the course of 45 to 60 minutes. You will be moved into the recovery in an upright position to ensure the chemical does not drain away from the nerve prematurely.
Most patients go home two or three hours later with marked resolution of their pain. You may experience some swelling or bruising. Your doctor will prescribe pain medications and, if necessary, give you a plan to gradually discontinue your seizure medications.
Glycerin/glycerol rhizotomy risks include bleeding, infection, nausea, vomiting, a small chance of sensory change (feeling of numbness) and anesthesia complications. Your pain may recur when the nerve grows back (usually within one to six years), but if this happens, the procedure can be repeated.
This procedure is similar to the glycerin rhizotomy, but instead of using a chemical to destroy the nerve fibers, a special needle is used with an electrical current, which burns the fibers. The outcome for pain relief is very good, but this procedure has a higher likelihood of causing sensory change (feelings of numbness in the face) than the chemical method.
It is often used for patients who do not get complete relief from glycerin or those who have recurrent pain and may need assistance to get through scar tissue. As with glycerin rhizotomy, the pain can return when the nerve regrows. The procedure can be repeated for recurrent pain, or you and your doctor may decide on another type of procedure.
This is the most permanent and curative procedure that exists today for treatment of trigeminal neuralgia. It is usually offered to patients who are in reasonably good health and are not too advanced in age (70 years is a usual cut-off age). This is invasive brain surgery, and takes about two - three hours in the operating room under general anesthesia. Patients can expect an overnight intensive care stay and about three days in the hospital.
The microvascular decompression procedure involves an incision behind the ear (About five inches long from top to bottom), made behind the hairline so it will not show when the hair grows back. The scalp is divided and a quarter sized piece of skull will be removed. Using an operating room microscope, the surgeon goes down to the level of the brainstem and identifies the nerve and the blood vessels that run concurrently with the nerve. The purpose of the surgery is to remove or pad the vessels so they cannot compress or irritate the nerve. The patient is taken to the intensive care unit after surgery, where they stay overnight. They are then transferred to a regular neurosurgical floor and begin to increase their activity and diet. Most patients experience a pressure-like headache across their forehead and incisional pain. Most feel the trigeminal neuralgia is gone, however. It is normal for patients to feel fatigued and need a lot of rest. Our team recommends a month of recuperation at home, and restricted driving for two weeks after surgery. The risks of this surgery include bleeding, infection, numbness or weakness of the face or eye, other cranial nerve dysfunction including hearing loss, seizures, paralysis, coma and death. It is very important to select a surgeon who is very familiar with this procedure and does a high volume of them. It should also be noted that although this is the most permanent, curative procedure, there can be about a 20 percent recurrence in pain, probably due to the regrowth of a blood vessel.
Recurrent Pain - It has been our experience that if pain recurs, most patients still have the same choices that they had initially. Most patients can choose to repeat their procedure, or try any of the other procedures that are available within the usual limitations.
Request an Appointment
To request an appointment or refer a patient, please contact the Johns Hopkins Trigeminal Neuralgia Center at 443-997-1808.
Request an Appointment
Adult Neurology: 410-955-9441
Pediatric Neurology: 410-955-4259
Adult Neurosurgery: 410-955-6406
Pediatric Neurosurgery: 410-955-7337
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