Introduction

Mr Hamlyn has a specialist interest in this field.  Hence we provide information here.

There are many causes of chronic pain affecting the face. These may range from anything as common as simple tooth decay to some rarer conditions. We have discussed the main causes we see at The Spine Surgery London and how best to treat them.

Please click here for a general summary of other causes of chronic facial pain.

What Is Trigeminal Neuralgia?

Neuralgia is a word meaning nerve ("neur...”) pain ("...algia"). There are two "trigeminal nerves", one each supplying sensation to the right and left side of the face.  They both have three branches (hence "tri...") which supply the forehead, cheek and jaw.

What Are The Symptoms?

The pain typically only affects one side of the face. It can be severe and is of an unpredictable, paroxysmal nature.  It is often described as; "burning, stabbing, electric or shooting". Whilst it is often mild, for many patients it can be experienced as a violent and excruciating pain.  These severe pains typically only last for a few seconds. It more commonly affects the jaw and cheek area, though may cover the whole of one side of the face.

To read more about the symptoms of trigeminal neuralgia, please press here.

To read extended information regarding what causes it or who it affects or how Trigeminal neuralgia is diagnosed, please press here for an information pack.

What Medicines Are Available?

The most powerful medication is Carbamazepine (Tegretol).  This is an old and well established drug which was developed primarily for use in epilepsy.  It dampens the activity in excitable nerves and in this instance its effect is to manifest on the trigeminal system.  Carbamazepine may cause a rash and a number of other rarer side-effects which you may wish to discuss with your doctor.  You will need to have a regular blood test. You may need to take large quantities of the drug.  Its principal side-effect is drowsiness. However, for the majority of patients, Carbamazepine is safe and all that is required.

Other anticonvulsants have been tried and these include Lamotrigine. This drug has to be started at a low dose and gradually increased if the principal side effect of a rash is to be avoided. Gabapentin is another though this may be built up quite quickly. Sodium Valproate (Epilim) is another and may be used instead of or in combination with Carbamazepine.  They may well be less effective though may be better tolerated, i.e. cause less drowsiness.

Baclofen is a muscle relaxant.  Seldom will it work on its own, though it may be effective in combination with Carbamazepine or its alternatives.

None of these drugs are available over the counter and you will need a prescription from your doctor.

None of the standard pain killers, however strong, seem to work on trigeminal neuralgia and you should stop them as they will add to the cocktail effect of the medicines without contributing to the pain relief.

For extended information regarding medications for neurological pain, please press here.

What Form Does Surgery Take?

There are many types:

Interrupting the nerve:

A number of different methods are used to interrupt the nerve impulses. Whilst this may relieve the pain it will nearly always leave an area of lost feeling or numbness on the face. The interruption can be made at one of three sites.

Please press here for an information pack, if you would like to read more about the different sites used in surgery.

Decompression of the Nerve

The operation of "neurovascular (nerve vessel) decompression" was developed in a bid to provide pain relief without nerve damage and consequent numbness. 

In this procedure, the blood vessel found compressing the nerve as it emerges from the brain stem is mobilised free from the nerve and a soft pad placed between them.  In 90-95% of patients, immediate pain relief is provided.  Most published accounts have shown that about 75% of patients will still be pain free some three to five years later.  Whilst recurrence may still occur after 5 years of relief, rarely does the procedure produce loss of sensation. 

In perhaps 10% to 15% of patients, no blood vessel is found or one that is very small and thought not to be significant. In these circumstances, we would routinely partially section the nerve so that some relief is gained by the operation. In some special circumstances, patients elect not to have this done in the event of a negative exploration and can then expect to still have pain thereafter. Some surgeons only offer a decompression if the MRI shows a blood vessel. However, sometimes these show a vessel which in reality is not there and on others no vessel when one in fact is present i.e., MRI scans of the small, deep vessels may yield false positive and false negative results. Whilst the accuracy of MRI is increasing, we prefer that you give us consent to section the nerve if we feel it necessary during the operation.

What Should I Have Done?

If your troubles are controlled by medication, then this is certainly the best mode of treatment.  Broadly speaking, two groups of patients go forward for other treatments; those in whom the tablets never gain control of the pain and those in which the medications cause intolerable side effects. In these eventualities, you will need to give careful consideration to which treatment you would wish to have. This is something you will need to discuss with a specialist.

A sensible guiding principle is to put aside the theories relating to the cause of trigeminal neuralgia and concentrate on weighing the potential benefits and risks of the various treatments. How likely is it to work, for how long will the benefit last and to what risk does it expose me as an individual?

A general recommendation has been that for young, healthy patients the neurovascular decompression operation is the most appropriate. It provides pain relief without numbness and usually does so in a lasting manner. For those who are unwell, are elderly or frail, cannot afford the time or are unwilling to take the risk the usual suggestion is to treat the condition with simpler techniques. The benefits will usually be of lesser duration and will usually then come with an associated numbness.

However the procedure can be repeated and subsequently one can go on for more definitive surgery.

You will need to consider these factors carefully and should feel under no pressure to accept one or the other as you will receive good support whatever your decision.

GLOSSOPHARYNGEAL NEURALGIA

This is a much rarer condition and may often be confused with trigeminal neuralgia. The pain is of an identical nature though affects a different area. Glossopharyngeal neuralgia is usually felt at the base of the tongue, the back of the throat and may radiate to the ear. It affects only one side of the head. The same areas are affected by hypersensitivity and the pain may therefore be triggered by touching the ear or swallowing.

The investigations of this pain will be along the same lines as that for trigeminal neuralgia. The medicines used in its treatment are also the same as those used in trigeminal neuralgia. Because of its rarity, surgical treatment for those patients in whom the pain breaks through the medications is less established. You will certainly need to discuss this carefully.

To read more about glossopharyngeal neuralgia, please press here.

POST-HERPETIC NEURALGIA

This is a form of chronic facial pain which follows an attack of shingles on the face.

Shingles is caused by the chicken pox virus which most people get as a child. Also known as the herpes zoster virus, shingles usually occurs in older people when the organism has been lurking in the body for many years and suddenly attacks a single nerve. It will most often affect a nerve supplying the skin of the trunk though it can affect the nerve supplying the head and face. It will never cross from one side of the face to the other.

Please click here to read more about shingles.

What Treatments Are Available?

The effects of treatment are much better when given early. If after an attack of shingles on the face you still have pain a month after the rash has settled, you should go to your doctor immediately. Ordinary painkillers usually have little effect and so may in fact only waste valuable time.  The principal drug used for this condition is Amitriptyline which is a drug more commonly used for depression, though has very powerful effects on certain forms of nerve pain. You may need to take the Amitriptyline for two or three weeks before it provides relief.

Other drugs such as creams and lotions, or the anticonvulsant medication Carbamazepine (Tegretol) may also be used. Surgical procedures to cut the nerve, such as those used in trigeminal neuralgia, are always ineffective.