When to see a doctor
If you experience facial pain, particularly prolonged or recurring pain or pain unrelieved by over the counter pain relievers, then see your doctor.
Welcome to Jaslok Hospital, one of the best Trigeminal Neuralgia treatment Hospitals in Mumbai, where we are committed to providing top-notch care and cutting-edge treatments for patients suffering from this debilitating condition.
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For the best Trigeminal Neuralgia hospital in Mumbai, consult Jaslok Hospital. If you or someone you know is suffering from TN disease or trigenic neuralgia, we will provide you with the most effective assistance, the most compassionate care and the most eternal solutions
Trigeminal neuralgia (TN) is also called tic douloureux (Tic).
The International Association for the Study of Pain (IASP) has defined Trigeminal neuralgia (TN) as “sudden, usually unilateral, severe, brief, sharp shooting, and stabbing, recurrent pains in the distribution of one or more branches of the fifth cranial nerve (Trigeminal nerve), which carries sensation from face to brain.”
The pain involves the jaw and lower face; sometimes it affects the area around the nose and upper part of the eye. Strong intense, stabbing, electric shock-like pain is caused by irritation of the trigeminal nerve.
Epidemiological evidence shows the prevalence of TN to be approximately 4–28.9/100,000 persons worldwide. Women are affected 1.7 times more than men. Onset is usually after age 50 years and increases with advancing age.
Hypertension is a risk factor in women, but the evidence is less clear for men. Moving ahead, we will also have questions such as whether is trigeminal neuralgia curable?
A history of Trigeminal neuralgia (TN) in a first-degree relative is also a minor risk factor.
Trigeminal neuralgia is a distressing form of nerve pain that targets the face. It arises when the trigeminal nerve, responsible for relaying sensation from the face to the brain, becomes irritated or compressed, often due to a blood vessel or other issues. The pain typically strikes suddenly, proving intense and electric-like in nature. It can affect one side of the face(mostly) or both.
If you may get severe shooting or jabbing pain that may feel like an electric shock.
Sometimes, pain affects one side of the face at a time, pain may rarely affect both sides of the face.
You can get a constant aching, burning feeling that may occur before it evolves into the spasm-like pain of trigeminal neuralgia.
You can face shooting or jabbing pain, “burning”,, “electric shock-like”, “pressure”, “stabbing, that makes you feel like an electric shock. Pain or attacks of trigeminal neuralgia can be triggered by certain actions or movements like,
Pain in areas supplied by the trigeminal nerve, including the cheek, jaw, teeth, gums, lips, or less often the eye and forehead.
Learn about the differences between dental pain and trigeminal neuralgia in our blog post: Dental Pain vs. Trigeminal Neuralgia: How They Differ in our blog post: Dental Pain vs. Trigeminal Neuralgia: How They Differ
The most common cause of typical TN is arterial/venous compression of the trigeminal nerve in the posterior fossa resulting in focal demyelination of the nerve root entry zone
The theory of neurovascular compression is based on three concepts:
(1) A normal blood vessel compresses the nerve in its course through the basal cisterns;
(2) The nerve is compressed in the root entry zone, the area of transition from central to peripheral myelin, which is particularly sensitive to pressure.
(3) Compression results in demyelination and ephaptic (i.e., extrasynaptic)the transmission of impulses from touch fibers to pain fibers, which results in the paroxysms of pain.
Focal demyelination of the nerve root entry zone leading to TN can also occur secondary to lesions such as tumors, cysts, or multiple sclerosis (also called SYMPTOMATIC TN).
Trigeminal Neuralgia flares can be triggered by seemingly harmless activities, such as eating, drinking, or even a gentle breeze against the face. While the precise cause of these sudden flare-ups of pain is not entirely known, recognizing and steering clear of potential triggers can play a vital role in effectively managing the condition.
Diagnosing Trigeminal Neuralgia requires a thorough evaluation of the patient’s medical history, a neurological examination, and imaging tests like MRI or CT scans. At Jaslok Hospital, our team of experienced specialists follows a comprehensive approach to accurately diagnose Trigeminal Neuralgia.
Diagnosing trigeminal neuralgia involves a detailed medical history, physical examination, and sometimes imaging tests like MRI or CT scans, although the diagnostic criteria is mainly clinical. Other criteria are:
Beyond medical and surgical interventions, effectively managing trigeminal neuralgia involves implementing specific lifestyle adjustments and self-care strategies. Our team offers comprehensive guidance on the following aspects:
Stress can intensify episodes of pain, and acquiring stress-reduction techniques can prove beneficial in easing the condition’s impact.
Steering clear of trigger foods and adhering to a balanced diet can aid in managing the condition and its symptoms.
Maintaining excellent oral hygiene and prioritizing dental care are crucial, as even routine dental procedures can trigger painful episodes.
At Jaslok Hospital, we go beyond medical treatments and extend our support to patients and their families throughout their journey with Trigeminal Neuralgia. Our patient support programs offer valuable resources, educational materials, and emotional assistance to foster a sense of community and understanding.
Jaslok Hospital is renowned for its excellence in neurology and neurosurgery. Our state-of-the-art facilities, coupled with the expertise of our skilled medical professionals, make us a trusted choice for treating Trigeminal Neuralgia. We prioritize the well-being of our patients and aim to provide a comfortable and nurturing environment for their recovery.
Our esteemed team of doctors at Jaslok Hospital includes some of the finest Trigeminal Neuralgia specialists in Mumbai. Their dedication to excellence, along with their empathetic approach, ensures that patients receive world-class care. The team is led by the best Neurosurgeon in India, Dr Paresh K Doshi. They possess a deep understanding of the condition and employ the latest medical and surgical advancements to ensure the best possible outcomes for our patients.
Trigeminal neuralgia symptoms may include one or more of these patterns:
Sudden, sharp, stabbing, or electric shock-like facial pain.
Painful episodes triggered by activities like touching the face, brushing teeth, chewing, or speaking.
Attacks that last anywhere from a few seconds to several minutes.
Facial pain that may be accompanied by involuntary muscle spasms or twitching.
Episodes may recur for days, weeks, or even months, with some pain-free intervals in between.
Discomfort localized to areas served by the trigeminal nerve — commonly the cheek, jaw, teeth, gums, or lips; occasionally affecting the eye or forehead.
Typically affects only one side of the face at a time.
Pain may be confined to a specific area or spread across a broader region.
Rarely occurs during sleep.
Over time, the episodes may become more frequent, longer, and more intense.
When to see a doctor
If you experience facial pain, particularly prolonged or recurring pain or pain unrelieved by over the counter pain relievers, then see your doctor.
In Trigeminal Neuralgia, also called tic douloureux, the trigeminal nerve’s function is disrupted. Usually, the problem is 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.
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.
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.
Triggers
A variety of triggers may set off the pain of trigeminal neuralgia, including:
Trigeminal neuralgia, a painful condition of the face, is characterized by stereotypic symptoms and (absence of) signs that usually allow its clinical diagnosis. The average age of onset is around 50 years. Pain is in the distribution of one or more divisions of the trigeminal nerve and is labeled as V1, V2 or V3 neuralgia. The pain is lancinating and described as “shock like”, “bolt out of the blue”, “shooting pain” etc. It is brief in duration, lasting for few seconds to couple of minutes. In a typical trigeminal neuralgia, the patient is pain free between the attacks. The pain is precipitated by triggers.
Your healthcare provider typically diagnoses trigeminal neuralgia based on a detailed account of your symptoms, especially:
Pain Type: The pain is usually sudden, brief, and often described as sharp or like an electric shock.
Pain Location: The specific areas of your face affected help determine if the trigeminal nerve is involved.
Pain Triggers: Common triggers include speaking, eating, touching the face, or even exposure to wind or a light breeze.
These include simple actions like brushing the teeth, washing face, mere touch or even a breeze of air. During the acute attacks, the pain is severe enough to compromise hygiene or diet. In some patients the pain is so excruciating that they start considering the idea of suicide. In a typical case of TN, the disease is characterized by remissions with or without medical treatment. The period of remission is variable and after a few years of disease the remissions do not occur. Patients with TN should not have neurological deficits, and if such is present a CT scan or MRI should be carried out to rule out other pathology. CT/MRI should also be performed if the pain is atypical. 1% of patients with multiple sclerosis (MS) develop trigeminal neuralgia and 3% of TN patients suffer from MS.
In patients suffering from TN there is extreme hypermyelination, demyelination, and tortuousity of hypertrophied axons. Kerr observed that the myelin disintegration is far more pronounced in the patients with trigeminal neuralgia than normal patients. These changes are noted at the level of peripheral branches of trigeminal nerve, gasserian ganglion, and trigeminal rootlets and also in descending spinal trigeminal tract. Though the cause of this is not known vascular compression of the trigeminal rootlets by either artery or veins at the level of the root entry zone is put forward as one of the cause.
In patients with typical TN, radiological investigations are not necessary. However, when performed, MRI (Cis images) may reveal vascular loop adjacent to the trigeminal nerve root entry zone on the affected side. However, this is not a diagnostic finding for TN, as in many cases patients suffer from TN even in the absence of the vascular loop. In patients desirous of undergoing Microvascular decompression, demonstration of the loop increases the chance of success.
People often ask us what is the best treatment for trigeminal neuralgia. Today, we will answer all of them.
we will understand how to cure trigeminal neuralgia. The first-line treatment for TN is Medical or Pharmacologic.
Carbamazepine is considered the most proven, first-line treatment for TN( Trigeminal Neuralgia), and it’s been shown to be effective in treating the condition. Carbamazepine should be offered as the initial treatment for patients with TN. Oxcarbazepine has also been shown to be effective for treating patients with TN.
Doctors usually prescribe carbamazepine (Tegretol, Carbatrol, others) for trigeminal neuralgia. Other anticonvulsant drugs that may be used to treat trigeminal neuralgia include oxcarbazepine (Trileptal).
Gabapentin and Pregabalin as an add-on agent for patients already taking carbamazepine or oxcarbazepine.
Lamotrigine
Vixotrigine
OnabotulinumtoxinA is a neurotoxin derived from Clostridium botulinum. The mechanism involves inhibition of the release of acetylcholine at the neuromuscular junctions, resulting in reduced muscle contraction, mitigation of peripheral sensitization, and, secondarily, suppression of central sensitization, to relieve pain and twitching
The main problem with treating TN patients with AEDs, even if they are tolerated initially, is that the treatment does not address the vascular compression cause present in 95% of patients, nor the fact that TN is a progressive syndrome.
Therefore the usual result is that, over time, patients require a higher and higher medication dose to achieve the same degree of pain relief, until a point is reached, at which either the medication no longer controls the syndrome or the patient can no longer tolerate the medication side effects.
Surgical interventions are divided into Nonablative (nondestructive) procedures and Ablative (destructive).
Posterior Fossa Exploration / Microvascular decompression (MVD)
Posterior Fossa Exploration: Microvascular Decompression and Partial Sensory Rhizotomy Exploration of the trigeminal root in the posterior fossa is a major operation with a 0.2–0.5% risk for mortality and major morbidity.
By a retrosigmoid posterior fossa approach, in which a blood vessel in contact with the trigeminal nerve is dissected free and prevented from re-impinging on the nerve by placing a Teflon pad between the two structures or by transposing the vessel to a different position.
This operation preserves the anatomical integrity of the trigeminal nerve, as well as its function in most cases. Posterior fossa microsurgery, whether performed by microvascular decompression (MVD) or partial sensory rhizotomy, is the most effective treatment of typical TN and has provided complete pain relief in 73% of patients at 5 years
Lesioning (chemical, thermal, or mechanical destruction of the trigeminal nerve)
RADIOFREQUENCY THERMOCOAGULATION
Radiofrequency rhizotomy is based on temperature-dependent selective destruction of pain-transmitting C fibers whiles sparing the A-delta fibers.
We recommend RFTC for most patients undergoing their first surgical treatment for typical Trigeminal Neuralgia, TN in multiple sclerosis and patients who have failed Microvascular Decompression.
This is a day care procedure. Preoperative workup involves evaluation for fitness to undergo short general anesthesia.
The patient has explained the procedure in detail and what to expect during the procedure so as to ensure adequate cooperation.
The procedure involves retrogasserian needle placement by the percutaneous technique. The needle is introduced through a point 2.5 cm lateral to the angle of the mouth on side of the lesion.
It is passed medial to the mandible and aimed in the direction of the petrous bone and clivus junction, seen on lateral fluoroscopic view.
The medial part of the foramen ovale is entered. Oblique view localizing the foramen is useful in case of difficult penetration.
Once the needle is in position, the appropriate trigeminal division is stimulated using the current from the radiofrequency lesion generator.
The patient typically experiences paraesthesia in the territory of his pain. In case he does not feel the paraesthesia in the desired territory, the needle position is adjusted. Once the distribution of the paraesthesia is confirmed a short general anesthetic (IV propofol) is administered and the division is lesioned using 70oC current for 60 sec.
The patient is woken up while the needle is still in place. He is asked to check if he has got adequate pain relief. This procedure is suitable for the second and third division TN. For the first division TN supraorbital block and if successfully followed by supraorbital neurectomy.
Results of RFTC : We have been performing RFTC for last 15 years .we have compared our results with those published in the literature( Table 2).
| Literature review (6205 cases) | Personal Series ( 395 cases) | |
| Pain relief | 98% | 92% |
| Recurrence | 23% | 20% |
| Mortality | .03 | 0.0 |
| Keratitis | 1 | 0 |
| Dysesthesia | 22 | 18 |
| Anaesthesia dolorosa | 1 | 1 |
Table 2 – Results of RFTC
(Percutaneous Balloon Microcompression)
In this procedure, the trigeminal nerve is compressed with a small balloon to induce ischemic damage on the rootlets and ganglion cells. Once the entry has been gained to the Gasserian ganglion, a Fogarty embolectomy catheter is inserted through the needle and inflated with nonionic, water-soluble contrast dye until the balloon becomespear shaped.
The length of time for inflation varies. Despite insufficient quality data on this technique, the results appear to be comparable to those after RFT.
However, transient masseter weakness affects virtually all patients treated with this technique, and vascular injury and aseptic meningitis appear to be more common than with other ablative techniques.
Glycerol is a mild neurotoxic substance that has a slow, nonselective neurolytic effect as it diffuses around the surface of the nerve. Recurrence rates following glycerol rhizotomy are the highest of all the ablative techniques.
SRS delivers a high dose of radiation, usually 70–90 Gy, to a small area (isocenter) of the cisternal portion of the trigeminal nerve.
The procedure is carried out under local anesthesia with light intravenous sedation and is typically conducted on an outpatient basis. Same-day MRI is performed to provide accurate stereotactic information about the location of the trigeminal nerve.
This surgery targets the dorsal root entry zone (DREZ) of the trigeminal nucleus caudalis in the brainstem. It is performed with a radiofrequency electrode producing coagulation along the posterolateral sulcus along the dorsal root entry zone, in the posterior aspect of the craniocervical junction.
The objective of the lesion is to interfere with the transmission of pain stimulus through the secondary neurons in this region. When this pain pathway is blocked with the DREZ procedure, the pain signal cannot reach the brain and decreases the processing of pain.
Neuromodulation is a promising therapeutic strategy for the treatment of neuropathic facial pain disorders.
Leads are placed in the nerve distribution with connections to a pulse generator in the subclavicular fossa.
PNS for trigeminal neuralgia includes neurostimulation of the supraorbital and infraorbital nerves which is Transcutaneous Supraorbital Neurostimulation, Infraorbital Nerve Stimulation, and Supratrochlear Nerve Stimulation.
It is similar to PNS, except electrodes are placed in the area of pain rather than on the nerve itself.
The even less invasive transcutaneous electrical nerve stimulation (TENS).The TENS unit is external electrodes on pads, electrodes are placed just before the ear, the other in the region of the affected nerve branch.
Gasserian Ganglion Stimulation: Patients with pain secondary to the damaged nerve or ganglion as occurs after some poorly performed surgery for trigeminal neuralgia or in cases of nerve infiltration by tumors, experience burning or nagging pain in the distribution of the trigeminal nerve. This is known as trigeminal neuropathy.
Neuromodulation by the way of gasserian ganglion stimulation or motor cortex stimulation is the only sensible alternative for treating this pain if the medical treatment fails. This involves implantation of the electrode at the target site and delivering current to the target nerve or cortex through a pacemaker.It is presumed that this will either increase their pain threshold or block the painful impulses from the periphery to relieve pain. This is a highly advanced form of treatment available at only select centres like Jaslok Hospital.
Alternative treatment encompasses a broad range of practices, therapies, and treatments that exist outside the realm of conventional Western medicine. While some alternative treatments may lack extensive scientific validation, many individuals report symptom relief and an improved quality of life when used appropriately and in conjunction with traditional medical treatments. Here’s an elaboration on complementary and alternative therapies used for trigeminal neuralgia:
Acupuncture involves inserting thin needles into specific points on the body to restore balance and alleviate pain. Based on traditional Chinese medicine, acupuncture is believed to enhance the flow of life energy, or “qi,” through pathways in the body. For trigeminal neuralgia:
Limitations:
Biofeedback is a mind-body technique that teaches individuals to control physiological functions like heart rate, muscle tension, and skin temperature using monitoring devices.
Limitations:
Chiropractic care focuses on the musculoskeletal system, particularly spinal alignment, to alleviate various health issues. For trigeminal neuralgia:
Limitations:
Certain vitamins and minerals are thought to play a role in nerve health and could provide relief from trigeminal neuralgia symptoms:
Limitations:
Dietary changes and specific nutrients might support nerve health and reduce inflammation, which can exacerbate trigeminal neuralgia:
Limitations:
Lack of Scientific Validation: Most alternative treatments lack rigorous research and clinical trials to support their efficacy and safety for trigeminal neuralgia.
Delayed Effective Treatment: Relying solely on alternative therapies may delay timely medical or surgical intervention, potentially worsening the condition.
Symptom Management Only: These therapies focus on alleviating symptoms rather than addressing the root neurological cause of trigeminal neuralgia.
Inconsistent Outcomes: Results are highly individual and unpredictable, with some patients experiencing no relief at all.
Potential Interactions: Alternative treatments may interfere with prescribed medications or exacerbate symptoms if not used under medical supervision.
While alternative treatments may provide some relief for symptoms of trigeminal neuralgia, they should not be used as the primary approach to managing the condition. These therapies are best considered complementary to conventional treatments and must always be discussed with a healthcare provider. Early and effective medical or surgical intervention remains the cornerstone of managing trigeminal neuralgia for long-term relief.
