Q. I have trigeminal neuralgia. Medications haven't helped. What are my other treatment options?
A. Trigeminal neuralgia causes pain in the face. The pain can be so bad that it disrupts a person's life.
You have two trigeminal nerves, one on each side of your face. These nerves detect touch, pain, temperature and pressure. If you pinch your lip, trigeminal nerve endings in your lips send pain signals up the nerve and into your brain, where the pain registers.
In trigeminal neuralgia, a nerve starts to malfunction, registering pain when there's no apparent reason for it. People suddenly have intense, "stabbing" or electrical shocklike facial pain. The pain can be excruciating and can occur anywhere between the jaw and forehead.
The painful symptoms come and go. You may experience repeated painful episodes over days, weeks or months. Then you may enjoy a pain-free stretch of months or years. But then it returns, and you feel betrayed: You thought you were rid of it. You live with the knowledge that it might come back, so even if you are free from pain you are not free from apprehension.
The irritation in a trigeminal nerve is usually near the nerve's origin, deep within the skull. In most cases, an abnormal blood vessel pressing on the nerve causes the irritation. Occasionally, multiple sclerosis can lead to trigeminal neuralgia. In some cases, we just don't know the cause.
Treatment usually begins with the anticonvulsant medication carbamazepine (Tegretol, others). This drug decreases the ability of the trigeminal nerve to fire off the nerve impulses that cause facial pain. If carbamazepine doesn't help, another anticonvulsant medication may be more effective for you. A muscle relaxant, either alone or in combination with an anticonvulsant, can also help.
Brief use of narcotic pain relievers, such as oxycodone, hydrocodone or morphine, can help manage episodes of severe pain.
You say medications haven't helped you. If you've tried the medicines I've mentioned, then there are other types of treatment to discuss with your doctor:
• Rhizolysis: Part of the trigeminal nerve is temporarily inactivated. This may be done using a heated probe, an injection of glycerol, or a tiny balloon inflated near the nerve to compress it. Rhizolysis provides immediate relief for most people, but it doesn't prevent the condition from returning.
• Stereotactic radiosurgery: This is a form of radiation therapy in which tiny beams of radiation are used to inactivate part of the trigeminal nerve. This is a newer treatment option, and its long-term success rate is not known.
• Microvascular decompression: In this delicate surgical procedure, a surgeon opens your skull and repositions the blood vessel that is pressing on your trigeminal nerve. The procedure has a high success rate, and most patients gain long-term relief. It has been a really important advance. I just wish it had been available to some of my patients with trigeminal neuralgia 20 to 30 years ago.
• Dr. Komaroff is a physician and professor at Harvard Medical School. Go to his website to send questions and get additional information: AskDoctorK.com.