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Trigeminal Neuralgia: Facial Pain with Options

People who have trigeminal neuralgia (TN) facial pain describe it as intermittent electrical shocks to a specific area. It can be triggered by eating, drinking, touching the face, or even a breeze wafting by. The length of the jolts can be very brief or become chronic with longer severe durations.

There is no one test that identifies TN, also called tic douloureux; it is diagnosed through patient history and examination. “There are other causes of facial pain that must be ruled out because treatments effective for TN won’t work for them,” says Joshua Dowling, MD, Washington University neurosurgeon. “It is important people be seen early in the condition. The quality of the pain changes over time and becomes less clearly defined as TN.”

MRI or CT scans of the brain can identify some causes of TN, such as tumors (usually benign), vascular malformations and multiple sclerosis (MS).

“The majority of cases, which typically occur in people over 50 and more often in women than men, are caused by compression of the nerve by a blood vessel bundle,” Dowling says.

Patients have more treatment options than ever before. When pain cannot be kept under control with medications, the neurosurgeon has a variety of tools with which to personalize treatment. Microvascular decompression (MVD), a form of brain surgery, can be higher risk but is the only approach that doesn’t involve injuring the nerve. Three different needle procedures, performed through the skin in the cheek, are performed with good success and all involve deliberately damaging part of the nerve to relieve pain while limiting the degree of numbness.

The most recent treatment option is stereotactic radiosurgery using the Gamma Knife.® This radiation-delivery device focuses about 200 separate beams of radiation on a tiny area of the nerve root. It allows a high dose of radiation to be delivered without affecting the surrounding structures. “The treatment is effective in most patients, but it can take up to two months to take effect,” says Dowling. “It is very safe.” Barnes-Jewish and Washington University were the first in Missouri to have the Gamma Knife. 

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