Options for Treating Neuropathic Facial Pain and Trigeminal

Neuralgia

Medical / Medications

There is a growing arsenal of ways to treat TN, including medications and surgical treatments. The first universally accepted treatment option is usually through medications. Surgical procedures are used for those patients who are unable to tolerate the medications, exhibit serious side effects, or if the medications do not control the problem. Medications are initially effective for many patients, but over a period of time their effectiveness may diminish and a surgical procedure required.

During all phases of medical treatment, patients need good communication with their physician and nurse to monitor their medication and response. The patient must understand the need to maintain a therapeutic blood level of medication for effective pain relief. Taking the medications irregularly is not effective.
 

Abrupt withdrawal of medications can cause serious side effects. Analgesics (i.e. aspirin, Tylenol, etc.) are not effective in addressing the pain of TN as it is of lightning-like intensity and the attacks are of brief duration. In general, narcotics have not been recommended as first line therapy for TN, as they have not been found to be effective for the characteristics of TN pain. While there are no controlled studies in TN, there is recent information that narcotics may be helpful in other painful conditions that have similar pain characteristics.
 

The primary drug used to treat TN is carbamazepine. It is also used to treat seizures. Initial relief is so readily achieved that many physicians consider its use as a means to confirm the diagnosis of TN. The drug is introduced slowly and increased to a level where the patient is pain-free or side effects occur.
 

Carbamazepine is available as Tegretol. A newer medication is oxcarbazepine, available as Trileptal. Extended release carbamazepine is available as Carbatrol and Tegretol XR.
 

In the last several years, oxcarbazepine (Trileptal) has been used more frequently as a first line drug for TN. It is structurally related to carbamazepine, and may be preferable due to a more favorable side effect profile.
 

Other medications used in the treatment of TN may include baclofen (Lioresal), gabapentin (Neurontin), clonazepam (Klonopin), sodium valporate (Depakote), lamotrigine (Lamictal), and topiramate (Topamax).

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Surgical

While medications provide effective management for many TN patients, medical therapy is often not a permanent solution for this problem. Fortunately for the TN patient there are several neurosurgical procedures that are available if medication no longer provides the desired results.
 

The dilemma for the TN patient considering surgery is how to select a surgical procedure since there are several modes of surgical intervention available. Procedures vary from nerve blocks/injections, percutaneous surgery (through the cheek), to open skull surgery and pinpoint radiation. Each procedure has certain advantages and disadvantages - ease of the procedure, effectiveness, long-term results, recurrences, complications, etc. There is no one medical or surgical treatment that is effective in all patients. The choice between a procedure done as a one-day or outpatient (e.g., radiofrequency coagulation or glycerol injection) or one requiring several days in the hospital (microvascular decompression) depends on the patient's preference, physical well-being, previous surgeries, presence of multiple sclerosis, and area of trigeminal nerve involvement (some procedures are particularly indicated when the upper/ophthalmic branch is involved). Undoubtedly, recommendations by the referring physician and by the neurosurgeon play a strong part in the patient's decision-making process. Many physicians are strong proponents of specific procedures. TNA is not an advocate for any single mode of treatment, but serves to provide information on the many treatments available so that TN patients can explore all their options in an informed partnership with their physician.

• Radiofrequency Rhizotomy (RF) - Percutaneous Stereotactic Radiofrequency Rhizotomy (or Electrocoagulation). This outpatient procedure is done under local anesthesia and sedation. A needle is placed through the cheek through which an electrode is inserted to heat the nerve and destroy the pain fibers.  See this surgery, step-by-step here.  Note:  The procedure called Percutaneous Stereotactic Rhizotomy or PSR in this depiction is the same procedure as RF or Radiofrequency Rhizotomy.

• Glycerol Rhizotomy - Glycerol Injection or Installation. Using a surgical technique similar to the RF (above) the surgeon injects glycerol into the cavity where the trigeminal ganglion (the central part of the nerve from which the nerve impulses are transmitted) lies. The nerve is bathed with the glycerol to damage the pain fibers.

• Balloon Compression - Percutaneous Trigeminal Ganglion Compression. Also a "through the cheek" procedure, the surgeon first inserts a catheter up to the trigeminal ganglion and then inflates a tiny balloon to compress the nerve and damage the pain fibers.

• Microvascular Decompression - (MVD). The operation is performed under general anesthesia where a small opening is made in the back of the skull on the side with the pain. The trigeminal nerve is viewed with a microscope and compressing blood vessels are removed and the nerve is padded with a soft pad (typically shredded Teflon).

• Stereotactic Radiosurgery - Gamma Knife, Cyber Knife, Novalis, etc.- This procedure requires no incision. Using highly focused beams of radiation, a lesion (an area of controlled damage) is created in the root of the trigeminal nerve. The nerve isn't burned as in a laser treatment, but the radiation causes the slow formation of a lesion in the nerve over a period of time to interrupt the pain transmission. 

All these procedures show varying degrees of immediate success and periods of long-term relief from pain. Generally, the average overall rate of success is 85% with about 25% of this group having some level of recurrence in 1-5 years. Many patients respond quite well when additional measures are pursued if the initial procedure is not successful or if the pain returns. There is no one procedure that is 100% effective in all cases. Therefore, it is imperative that the TN patient becomes as informed as possible about the surgical options available and understands fully the potential benefits and outcome possibilities of the procedures being considered.

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CAM - Complementary and Alternative Medicine

Over the years, TNA has accumulated anecdotal data concerning non-traditional remedies that patients have found helpful in treating their pain. TNA welcomes these reports and always responds. Some reports come from patients who have failed surgeries in their past, some from those who have found medication to be ineffective or bothersome and some from those with a simple desire to find a non-medical or a non-surgical response to their pain.  The volume of this data has increased since TNA expanded its Mission to include conditions related to TN, such as atypical TN and atypical facial pain, where medical and surgical treatments have seemed to be less effective.  Patients with such conditions, like patients with other forms of chronic pain, typically develop increasing interest in non-traditional remedies as they search for relief.

TNA has always been open to the use of complementary and alternative medicine (CAM).  Sessions at national conferences have been devoted to the subject with speakers on chiropractic, acupuncture, healing hands, hypnosis and nutrition, to name a few.  Editions of our newsletter, the TNAlert, have also addressed these issues.  Currently, we are assembling a task force to establish both guidelines for patients to follow in their use of such therapies and an informed basis for TNA to share with patients the anecdotal data we are collecting.

In pursuing this effort, TNA believes that one needs to treat the patient, not just the condition.  So, we need to take care of the mind and body as well as our specific facial pain condition.  CAM therapies are legion; some address the mind and spirit, some address the body.  Whichever therapy you intend to use, TNA advocates that you consider the following:

• Little clinical testing with respect to CAM has been performed according to accepted scientific standards;

• Anecdotal evidence suggests that some CAM works for some people but not for others;

• Failures in the use of CAM tend to go under-reported; 

     Also, before resorting to CAM, patients should perform some due diligence:

• Always research the safety and effectiveness of a product or treatment before use;

• Determine the expertise of the provider;

• Establish the cost and the time-frame in which treatment may be expected to be successful;

• Discuss the proposed treatment with your doctor; and

• Ask your local TNA support group or the TNA national office to put you in touch with patients who may have experience of the product or treatment you have selected.

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