FAMILY MEDICINE® COLUMN
By John C. Wolf, D.O.
Associate Professor of Family Medicine®
Ohio University College of Osteopathic Medicine

TRIGEMINAL NEURALGIA IS A REAL PAIN IN THE NECK ó AND THE TOOTH, TOO

Question: I had a terrible attack of tooth pain. After several trips to my dentist, my family doctor, and finally to a neurologist, they diagnosed my condition as trigeminal neuralgia. They say my teeth are fine and that the pain comes from a problem with the nerve. Can you tell me more about this condition?

Answer: Trigeminal neuralgia, which also goes by the name tic douloureux, describes a set of symptoms rather than a specific disease. The condition is one in which there is pain in the areas of the face and head served by all or part of the fifth cranial nerve. This nerve, as you have probably already guessed, is also called the trigeminal nerve. The condition can have several causes, and it strikes those over 50 years of age more frequently than it occurs in younger individuals. Women are also stricken with this more often than men.

The trigeminal nerve has three major divisions:

The ophthalmic nerve (the topmost branch) carries sensations from the eye and forehead to the brain;

The maxillary nerve (the middle branch) conveys sensation from the upper teeth, the upper lip, the ear, and the sinuses; and

The mandibular nerve (the lower division) transports sensation from the teeth of the jawbone and skin of the lower jaw and upper part of the neck.

While all three of these branches perform sensory functions like feeling pressure, pain and temperature, the mandibular nerve also performs motor functions. That is, it has fibers that control movement of the muscles that produce facial expressions and those used for chewing.

In trigeminal neuralgia, the pain can be limited to a single branch of the nerve, or it may involve two or all three. The pain typically occurs quite suddenly and at its onset is quite severe. Many describe it as an electric shock or a stabbing pain.

The initial period of intense suffering, the acute pain phase, subsides relatively quickly and is replaced by an aching pain. The acute pain phase may be triggered by minor activities such as chewing or a being touched lightly on the face. Often, the cycle of acute pain followed by less severe pain repeats itself over and over again. This can cause great anxiety on the part of the sufferer, who is constantly worrying when the next bout of severe pain will start. In fact, the severe pain and the anxiety can be so overwhelming that suicide is a real risk in untreated individuals.

Trigeminal neuralgia is not usually caused by an underlying medical problem. However, a tumor, either malignant or non-cancerous, pressing on the trigeminal nerve (or in a neighboring area of the brainstem) is the culprit about 8 percent of time. Likewise, multiple sclerosis is identified as the cause in about 3 percent of the cases.

If the pain of trigeminal neuralgia is produced by a tumor, it is usually best treated by surgery to remove the abnormal growth. The same is true if malformation of blood vessels need to be corrected.

Other sufferers are treated first with medications. If these fail to give satisfactory pain relief, your doctor may recommend a treatment that actually damages a portion of the trigeminal nerve. While this approach is generally effective at stopping the pain, it does so at the expense of making a portion of the face feel numb all the time. It's like permanently feeling that you have just come from the dentist's office. Most patients find this an acceptable trade-off for relief from the terrible pain of trigeminal neuralgia.

Family Medicine® is a weekly column. To submit questions, write to John C. Wolf, D.O., Ohio University College of Osteopathic Medicine, Grosvenor Hall, Athens, Ohio 45701.