Trigeminal Neuralgia is a syndrome that affects the trigeminal nerve, which supplies the sensation to the face. It is characterised by recurrent stabbing pain or electric jolt to the jaw or cheek region. Although it can happen at any age, it is more commonly seen in people over the age of 50.
Trigeminal Neuralgia can be varied but normally give painful moments along with the sensory distribution of the trigeminal nerve (including the cheek, jaw, teeth, gums, lips, or less often the eye and forehead). These episodes are normally severe shooting pains that can feel like an electric shock. Typically, they occur only on one side of the face; however, in rare cases, they can be bilateral. They can be triggered through touching or brushing the skin, or simple tasks like chewing or brushing your teeth, though the pain can also occur spontaneously without a ‘trigger’.
Commonly these attacks of pain last only moments; initially seconds to minutes. However, over time, these attacks can extend to days or weeks; in some cases, the pain can become constant and burning. Patients can develop a hemifacial spasm, where muscles on one side of their face either involuntary twitch or contract.
- DIFFERENTIAL DIAGNOSIS:
The sensory distribution of the trigeminal nerve overlaps the regions of pain that can be felt with injury to the Temporomandibular joint (TMJ). The TMJ is a joint and like all joints in the body can become injured or restricted in movement. Commonly the patient will also develop a click or multiple clicks when opening or closing their mouth. TMJ dysfunction is something that can be treated by physiotherapists with special training in the region.
Additionally, Cervicogenic Headache (headache coming from the neck) will commonly refer pain to the distribution of the trigeminal nerve. This occurs either directly by the spinal nerve of the upper cervical spine (C1, C2, C3) or via the trigeminal-cervical nucleus, a junction where sensory fibres of the descending tract of the trigeminal nerve converge with sensory fibres from the upper cervical nerve roots. This convergence allows for pain arising from a neck condition to present as pain in the head or face.
Cervicogenic headache is a complex condition that is commonly seen and treated by a physiotherapist who has completed post-graduate study in head and neck related pain. Cervicogenic headache requires careful, a thorough examination of the upper cervical spine and normally the treatment involves manual therapy and exercise.
Trigeminal Neuralgia normally occurs when the nerve’s function is disrupted by some form of pressure or contact. Most commonly, this is due to contact with a healthy blood vessel; however, it can also arise from contact with a tumour or following facial trauma.
Some neurological conditions that affect the myelin sheath, the wrapping around the nerve can also cause similar damage to the trigeminal nerve, in particular, Multiple Sclerosis. Less commonly it may be caused by stroke, other lesions or injury to the brain and some other neurological disorders that involve demyelination of the nerve.
- ANATOMY AND BIOMECHANICS:
The Trigeminal nerve is the fifth cranial nerve, a special category of nerves that originate directly from the brain, rather than as a branch of the spinal cord.
The peripheral aspect of the trigeminal ganglion gives rise to three divisions: Ophthalmic, Maxillary and Mandibular, which supply the sensation to the face.
(arterial compression of the trigeminal nerve)
The most common site of compression of the trigeminal nerve is as it exits the brain stem and passes in close proximity to a blood vessel: the superior cerebellar artery. This compression can cause wearing of the myelin sheath, a protective coating around the nerve, and leads to the erratic and hyperactive transmission of the nerve signals. Alternatively, the myelin sheath can be damaged by a tumour pressing on the nerve or other neurological conditions (e.g. Multiple Sclerosis)
The primary treatment for trigeminal neuralgia is pharmaceutical in nature. Normally your doctor will prescribe an anticonvulsant medication, similar to those used to treat epilepsy, as traditional pain killers aren’t effective with this condition.
If the patient has clear triggers that set off their symptoms, these should be limited or at least avoided. Other sites with possible referral to the face should be ruled out, e.g. TMJ or cervical spine
If this is ineffective, several surgical options can be considered.
- RETURN TO FUNCTION/SPORT
With the right combination of medication and management, trigeminal neuralgia is a very treatable condition. Most people are able to return to work and normal function with medication alone.
- 5 TIPS FOR MANAGEMENT
- Confirm the diagnosis with your health professional
- Avoid or minimise your triggers as able
- Review medications with your specialist to ensure adequate symptom management as time goes on.
- Aim to keep up regular exercise especially if the condition becomes chronic
- Ensure there is no referred pain from other sites