Trigeminal neuralgia

What is trigeminal neuralgia?

Trigeminal neuralgia is a disease of the fifth cranial nerve (trigeminal nerve). It is characterized by paroxysmal, very severe facial pain in the supply area of ​​one or more of its branches. The attacks last seconds to two minutes, but can repeat themselves in series. Those affected are often symptom-free between attacks; some experience dull intermittent pain.

• Classic trigeminal neuralgia: often caused by contact of a blood vessel with the nerve (neurovascular conflict).
• Idiopathic form: typical symptoms without a demonstrable clear cause.
• Secondary form: triggered by other illnesses, e.g. B. Multiple sclerosis, rarely tumors or after inflammation.

Anatomy: Course and supply areas of the trigeminal nerve

The trigeminal nerve is the large emotional nerve of the face. It branches into three main branches that serve different regions. Pain attacks usually affect one side of the face and are limited to certain areas.

• V1 (N. ophthalmicus): forehead, eye region, bridge of nose
• V2 (maxillary nerve): cheek, upper jaw, upper lip
• V3 (mandibular nerve): lower jaw, lower lip, chin; also contains motor fibers for chewing muscles

Typical trigger zones are often in the transition between the lip and cheek or in the area of ​​the gums and nose. Even light touching can trigger attacks.

Recognize symptoms

The pain is usually described as electrifying, lightning-like or knife-like. Häufig bestehen schmerzfreie Intervalle, eine sogenannte Refraktärzeit, direkt nach einer Attacke. The pattern of triggers is crucial for the diagnosis.

• Duration of the attacks: seconds to a maximum of two minutes
• Side-emphasized: almost always one-sided
• Triggers: Touch, speaking, smiling, chewing, brushing teeth, shaving, cold air
• Intermediate attacks: often symptom-free, occasionally dull residual pain
• Neurological status: usually without paralysis or deafness (except for secondary forms or after procedures)

Warning signs such as persistent sensory disturbances, double vision, hearing or vision problems, fever or skin rash suggest other causes and must be clarified quickly.

Causes and forms

In classic trigeminal neuralgia, there is often contact between a blood vessel and the nerve near the base of the brain. Pulsating pressure can cause irritation of the nerve fibers. The idiopathic form shows the same symptoms without any definite conflict being visible on the MRI.

• Neurovascular conflict: vascular-nerve contact with possible myelin damage
• Multiple sclerosis: demyelinating lesions in the brain stem can trigger trigeminal pain
• Rare: tumors of the posterior cranial fossa, cysts, vascular malformations
• To be distinguished: post-herpetic neuralgia (after shingles), dental and jaw diseases, temporomandibular joint disorders

Differential diagnoses: What can look similar?

Not all facial pain is trigeminal neuralgia. A detailed history and examination helps to avoid misdiagnosis and unnecessary dental treatment.

• Toothache, pulpitis, periodontitis
• Temporomandibular joint dysfunction (TMD), masticatory muscle myalgias
• Sinusitis (sinus infection)
• Postherpetic neuralgia after herpes zoster
• Atypical facial pain
• Cluster headache, SUNCT/SUNA, migraine
• Otitis, neuralgia of the glossopharyngeal nerve
• Giant cell arteritis (in older patients, tender temples)

Diagnostics: This is how we proceed

The diagnosis is primarily clinical: the typical attack pattern and triggers suggest trigeminal neuralgia. Imaging is used to clarify the cause and rule out other diseases.

In Hamburg we coordinate the necessary steps and interdisciplinary collaboration with neurology, dentistry, ENT and – if necessary – neurosurgery.

Conservative treatment: medication first

The first-line treatment for trigeminal neuralgia is medication. The aim is to prevent or significantly reduce attacks. The adjustment is made individually and under observation of possible side effects.

• First choice: carbamazepine or oxcarbazepine
• Alternatives/supplements in case of intolerance or insufficient effect: lamotrigine, gabapentin, pregabalin, baclofen
• Therapy control: slowly increasing the dose, regular checking of blood counts/electrolytes as recommended by a doctor
• Information about side effects: fatigue, dizziness, nausea, hyponatremia (especially with oxcarbazepine), skin reactions
• Driving and work safety: Do not drive vehicles/operate machines if you are drowsy or have impaired vision

After clarification, we can consider peripheral nerve infiltrations (e.g. infraorbital, mental) or botulinum toxin A injections in selected cases. There is growing but still limited evidence for botulinum toxin: it can reduce attacks in some sufferers. We make decisions together and based on indications.

Non-drug strategies help to minimize triggers: protection from cold drafts (scarf, mask), lukewarm instead of cold drinks, soft toothbrush, if necessary lukewarm water when brushing teeth, chewing slowly on the unaffected side. A pain calendar supports therapy adjustment.

Interventional procedures: gentle but targeted

If medications do not work sufficiently or are not tolerated, minimally invasive procedures can be considered. The selection and timing depend on the cause, the affected branch and individual risk factors.

• Peripheral nerve blocks: temporary pain relief, can be used diagnostically and therapeutically
• Pulsed radiofrequency (pRF) of peripheral branches or on the Gasserian ganglion: can reduce pain without destroying the nerve
• Radiofrequency thermocoagulation, glycerol rhizolysis or balloon compression on the Gasserian ganglion: effective, but with a risk of sensory disturbances
• Stereotactic radiosurgery (e.g. Gamma Knife/CyberKnife): non-invasive, effect sometimes delayed over weeks to months

Possible side effects of rhizotomous procedures include numbness, dysesthesia or – if V1 is involved – reduced corneal sensitivity. The benefit-risk assessment is carried out on an interdisciplinary basis.

Surgical therapy: microvascular decompression

In the case of classic trigeminal neuralgia with demonstrable neurovascular conflict, microvascular decompression (MVD) in specialized centers offers the best chance of long-term freedom from symptoms. The vascular contact is released from the nerve and a buffer is inserted.

• Advantage: often good and lasting pain relief
• Please note: Surgery on the skull involves risks (including bleeding, infection, hearing loss, cerebrospinal fluid leak, stroke), and thorough information is required
• No guarantee of success; Recurrences are possible

Whether an operation makes sense depends on the individual situation. We provide you with open-ended advice and, if necessary, organize a neurosurgical presentation.

Everyday life and self-help: trigger management

Many sufferers find relief with small adjustments to their everyday lives. It is important to avoid being overcautious so as not to develop unnecessary fear of triggers.

• Avoid the cold: scarf, cloth or mask in windy conditions; lukewarm food/drinks
• Oral hygiene: soft brush, lukewarm water, short breaks
• Eating: small bites, chewing slowly, possibly soft food in phases of high irritability
• Stress reduction: relaxation procedures, regular sleep
• Documentation: Note attacks, triggers, medication intake
• Support: psychosocial counseling, self-help groups

Physiotherapy does not directly help against neuralgia, but can be useful for accompanying jaw joint or neck problems.

Our approach in Hamburg

In our practice at Dorotheenstrasse 48, 22301 Hamburg, care is provided in stages and in an interdisciplinary manner. We begin – in accordance with guidelines – with precise diagnostics and conservative measures.

All steps are carried out transparently and without promises of healing. We make decisions together based on the available findings and current evidence.

When should I urgently see a doctor?

• Newly occurring, persistent sensory disturbances, paralysis, double vision
• Fever, severe feeling of illness or rash on the face (indication of herpes zoster)
• Sudden, severe headache (“thunderclap”)
• Eye involvement: red, painful eye, dry cornea
• Tooth/jaw swelling, purulent signs of inflammation
• Bilateral trigeminal pain in younger patients (examination for multiple sclerosis, among other things)

Course and prognosis

The process is individual. Many patients achieve a significant reduction in attacks with drug therapy. Some parts experience fluctuating phases. If medication does not help sufficiently or is not tolerated, further step-by-step options are available. Complete follow-up care improves the long-term perspective.