Question

I have a condition known as tic douloureux or trigeminal neuralgia. I have had this for over ten years and the attacks get worse and last longer as the years go by. I have been taking Tegretol (carbamazepine) for all these years; but the side effects don't make me feel very good. Do you have any suggestions?

Answer

Trigeminal neuralgia, or tic douloureux, is a very painful and frustrating condition. This disorder involves the sensory part of the fifth cranial nerve (the trigeminal, or three-rooted, nerve). The trigeminal nerve collects sensations from the facial area. It has three branches. The ophthalmic branch serves the forehead, the maxillary branch the face from below the eyes to the lips, and the mandibular branch serves below the lips. A 'trigger point' can exist anywhere along the subdivisions of these major branches that will set off a painful episode. An example would be when one is chewing food and the nerve supplying the teeth is the trigger.

No one knows for sure the 'cause' of trigeminal neuralgia. A thorough diagnostic investigation should be done to rule out any possible cause within the cranial cavity (e.g. a tumor), so that a CT or MRI would certainly be warranted. Other, rare, causes may be an abnormal blood vessel in the brain, a stroke, a demyelinating nervous disease (e.g. multiple sclerosis), or a viral infection - especially after a herpes (shingles) attack, which usually involves the ophthalmic branch.

Treatment options include anticonvulsant medications, such as carbamazepine (Tegretol - the drug of choice) and phenytoin (Dilantin), and clonazepam. These drugs will give relief to many, but will fail in a significant number of patients. Muscle relaxants such as baclofen are also used to relax the 'tic' by working on the facial muscles. For cases non-responsive to medication, a surgical approach can be utilized that involves cutting the nerve roots (rhizotomy), destruction of part of the nerve ganglion, removal of any adjacent structures that may be 'pressing' on the ganglion, sometimes using laser techniques that are more specific and less damaging to healthy tissue. A relatively new approach to treatment is application of the botulinus toxin (Botox) to the affected nerve fibers.

Please discuss treatment options with your physician, and see if referral to a neurologist or neurosurgeon would be appropriate.

Links

• The Commonest Facial Pain
• Trigeminal Neuralgia Association