TNA Review of Neuropathic Facial Pain

By Alana Greca, BSN, RN

TNA (Trigeminal Neuralgia Association) Director of Patient Support

NOTE: Portions of this article are based on anecdotal information from patient calls and e mails.

CAUSE/SYMPTOMS

Neurosurgeon and member of the TNA Medical Advisory Board, Kim Burchiel, has proposed a classification system that divides neuropathic facial pain according to the cause of damage to the trigeminal nerve. OHSU Facial Pain Classification System

This classification system was used in the book, Striking Back!, and will be used here to provide continuity in terminology. Please be aware that other medical providers may use different terms for the same problems. This discussion includes trigeminal neuropathic pain, trigeminal deaffrentation pain and post herpetic neuralgia.

Trigeminal neuropathic pain (TNP)---facial pain which is  due to unintentional injury from such things as:

• facial trauma

• dental procedure

• complication of  sinus surgery or other ear, nose or throat operation

• or from side effects of stroke or diabetes.

Symptoms:

• if triggered, the pain is usually in the trigger area

• pain described as constant, dull, burning or boring

• numbness and tingling may also be present

• intermittent sharp stabbing pain may also occur

Trigeminal deaffrentation pain (TDP)---This is pain that occurs when parts of the nerve are severely injured and have little or no function as a result of intentional injury.

TDP occurs as a complication from surgeries done to treat TN pain, such as:

• Alcohol or glycerol injections

• Radiofrequency lesioning

• Balloon compression

• Neurectomies

• Radiosurgery

Deafferentation pain symptoms

Generally, continuous aching, burning quality – usually with numbness, tingling and/or hypersensitivity in the affected area. (“burning numbness.”)

In Striking Back! The Trigeminal Neuralgia and Face Pain Handbook, it is stated that “symptoms may even go beyond the trigeminal system….arm pain, shoulder pain, chest pain and even queasiness…”

Intermittent sensations like itching, crawling, pulling or pressure may occur.  If TN pain has been relieved, these symptoms will occur alone or in addition to TN pain, if the surgery is ineffective.

Anesthesia dolorosa

“…This is a seemingly impossible combination of both dense numbness and severe pain in the same area following an injury to that area.” There are several theories as to why pain would be felt in a profoundly numb area. The first is that somehow the touch nerve fibers were destroyed, but the pain fibers are still functioning. The second is that the brain center which monitors and interprets the nerve signals either remembers or substitutes signals when it is no longer is receiving impulses from the non-functioning nerve.

Facial Neuralgia Resources - AD

Center for Cranial Nerve Disorders - AD

Post herpetic neuralgia (PHN)--- This is pain which follows an attack of shingles (herpes zoster), because of viral damage to the nerve. If it affects the glossopharyngeal nerve, it gives throat pain; hearing difficulties result if the aucoustic nerve is damaged; drooping or paralysis of the face may occur when the facial nerve is involved; damage to the trigeminal nerve (usually the first branch area) presents as facial pain.

Symptoms

• Pain tends to be more constant than classic TN

• different descriptions of pain---sharp & jabbing; burning pain; deep and aching

• dull and borimg

• Along with the pain there is often skin sensitivity and sometimes an itching or numb feeling.

Facial Neuralgia Resources - PHN

E-Medicine/Web MD - PHN

Mayo Clinic- PHN

DIAGNOSIS

It is important that neuropathic pain be differentiated from trigeminal neuralgia.

Description of symptoms---the quality, characteristics, occurrence of pain is the most important means of accomplishing this.

The onset of pain was preceded by one of the causative events mentioned above.

TREATMENT

In post herpetic neuralgia, nerve damage from the virus can result in pain which lasts for months or years. The pain can resolve spontaneously or it may be permanent.

Regarding trigeminal neuropathic pain and deaffrentation pain, George Weigel in Striking Back advises “As with neuropathic pain, undergoing additional surgeries on the nerve is usually not going to help and may even make things worse. Deafferentation pain may, however, respond to some of the same medications and therapies used to treat neuropathic pain. Deafferentation pains may get better with time, but like neuropathic pain, they also may become permanent.”

DRUG

TREATMENT

Some of the websites for checking medication information

RX List - The Internet Drug Index  

Medscape.com

Drugs.com

IQ Health Drug Information Site

Search For Drug Information
Search for a specific drug or multiple drugs and read leaflets in English and Spanish.

Check For Drug Interactions
Check for drug-to-drug, drug-to-food interactions and check for allergic reactivity for many medications.

Drug Digest

DRUG

TREATMENT

Some of the websites for checking medication information

RX List - The Internet Drug Index  

Medscape.com

Drugs.com

IQ Health Drug Information Site

Search For Drug Information
Search for a specific drug or multiple drugs and read leaflets in English and Spanish.

Check For Drug Interactions
Check for drug-to-drug, drug-to-food interactions and check for allergic reactivity for many medications.

Drug Digest

Anticonvulsants

Neurontin and Lyrica for burning, aching pain

Tegretol, Trileptal, Keppra, Zonegran, Lamictal, Topomax as needed

Pub Med

Antidepressants

Tricyclics, such as Elavil and Pamelor

CNN Health Library

Others such as Effexor,  Cymbalta

Mayo Clinic Pain Medications

Topical

Hot pepper cream, Lidoderm

NGX-4010 (Transacin) being studied now for PHN

Clinical Trials

Narcotics/

Opiods

If effective, use as needed

Medscape Article - Opiods

Medscape Article - Management

Medscape Article - Fentanyl

IV

MEDICINE

Lidocaine

Ketamine

Medscape Article - Ketamine

Adenosine 5’-triphosphate (ATP)

Pub-Med - IV ATP

Pub-Med - Analgesic ATP

MEDICAL TREATMENT

Nerve Blocks

Cortisone and anesthetic agent which may

give pain relief for vary time—
hours, days, weeks

Emedicine - Injections

Botox Injections

If effective can provide pain relief for 2 to 3 months

In some is only effective for sharper pains, but not burning pain

Emedicine - Botox

Medicine Net - Botox

Pulsed Radiofrequency

Does not damage the nerve

If effective, pain relief for 2-3 months

Transcranial Magnetic Stimulation

Has been used as pre testing for motor cortex stimulation

Has been used for pain control and
the following site

^ (see note below)

SURGICAL TREATMENT

MVD

Generally, not effective;

 may be attempted if  MRI shows compression

Percutaneous procedures (radiofrequency, balloon compression, glycerol injection

Not usually done for neuropathic pain
because they could increase the
chance of complications, such as
deaffrentation pain and anesthesia
dolorosa

Radiosurgery

Gamma Knife, Cyber Knife, Novalis, etc.

Not usually done for neuropathic pain
because they could increase the
chance of complications, such as
deaffrentation pain and anesthesia
dolorosa

Motor Cortex Stimulation (MCS)

Can be used for neuropathic pain in all 3 branches

and with numbness, including anesthesia dolorosa

Piece of skull removed at top of head and

electrodes placed on covering of brain

Iniatially, all changes in settings are made  by

medical personnel

SpringerLink - Journal Article

CAM FOR NEUROPATHIC PAIN

Complementary and Alternative Medicine (CAM) is the title given to treatments which are not part of mainstream medicine. A variety of stances exist regarding CAM use:

• Some would never consider using untraditional modes of treatment. They have no belief in CAM and no faith in anecdotal information.

• Some people completely believe in and adhere to the superiority of CAM therapy. Their basic premise is that the core of health care is promoting wellness of the whole body through diet and supplements and through healthy life style changes, such as exercise, relaxation and stress reduction. Logically, no matter what the disorder or disease, the chance of recovery should be increased if a person is optimizing their mental and physical health. Traditional health practitioners often do not address these issues with their patients. Those who support alternative therapies often rely on testimonials of others experiences to evaluate the worth of any particular treatment.

• Many people are already using alternative therapies in addition to medications or other traditional treatments. I have talked with a few people who have been able to use a CAM remedy instead of medication. More often, facial pain patients tell me that CAM therapy lessens, but does not eliminate the pain, but by using both options, they can achieve better control. A recent study* showed 41% of the seniors surveyed were CAM users, that 80% felt these therapies were beneficial, but 58% , for a variety of reasons, were not sharing the information about their alternatives with their medical doctor. The most frequent reason was that the doctor was not asking, and if that is your experience, then you should take the initiative to provide this information. Not all physicians are supportive of CAM usage, but it is important that your doctor be aware of your complete treatment plan in order to assess any potential interactions.

Integrative Medicine

Traditional practitioners call for evidence-based medicine, so that all treatments, including alternative ones, would be scientifically studied and proven to be effective. There are many issues which make scientific study of some therapies difficult, but all alternative research will strengthen integrative medicine and increase available treatment choices. CAM at the NIH.

On its website, NCCAM (National Center for Complementary and Alternative Medicine) has a listing for 100+ CAM related research projects. While these are not directly connected to facial pain, some are related issues.  You may find a study being done for another health issue which is pertinent for you or someone you know. The website is below followed by a few examples:
NCCAM Funded Research and Rehab Research.

Nowhere does this blend of medical philosophies seem more appropriate than for those dealing with neuropathic facial pain.  No one medication or one therapy is usually effective for this type of pain. Those whom I have talked with, who are successfully coping with neuropathic pain, use a combination of medications (see conventional medications chart below) and as many of the CAM treatments as are useful to them (see CAM chart below).

Integrative Medicine: Sorting Fact From Fiction

Please note:

If alternative treatments are of interest to you, look for reputable practitioners in your area.  Be cautious of internet offers.

CAM TREATMENTS

MSNBC & Newsweek - Tips for Treating Pain

Answers.com - Glossary of Alternative Medicine

Other Medical Systems

Homeopathic Medicine

Naturopathic Medicine

Traditional Chinese Medicine (TCM)

Acupuncture, acupressure

Pub-Med - Acupuncture

WebMD - Arthritis Acupuncture

Blackwell Synergy - Acupuncture

Ayurvedic Medicine

Mind-Body Interventions

Prayer, Yoga, Pilates, Mental Healing

Bio-Feedback  Medscape - Biofeedback

Hypnosis  

Guided imagery   Forbes:  The Mind as Medicine

Meditation  NPR:  Meditation for Pain Management

Exercise  Mayo Clinic - Exercise

Sound, Art, Music, and Dance Therapies

Biologically-Based

Diet, Vitamins, Herbs   Medscape - Herbal Therapies

Supplements   Newswise - Antioxidants

B12  TimesDaily.com - A Primer on B12

Manipulative and Body-Based

Upper Cervical Chiropractic Care (UCC)

Accademy of UCC Organizations

National Awareness Campaign for UCC

Practitioner Database

Chiropractor, Osteopath, Cranio-Sacral Therapy, Massage

CNN Massage

Energy

Low Level Laser Therapy (LLLT)

Magnets, Electro-Magnetic Therapy, Therapeutic Touch, Reiki, Qigong, TENS Unit

Emedicine - Transcutaneous