Trigeminal Neuralgia

Trigeminal neuralgia (TN), also known as tic doloureux, is a paroxysmal lancinating pain that occurs in one or more of the distributions of the trigeminal nerve. The pain often occurs with sensory stimulation to the face or teeth, with patients being unable to eat or have anything touch their face. Spontaneous remission is common, with patient often having prolonged periods where they are symptom-free. This occurs in the general population in 4/100000 people but in those with multiple sclerosis have an incidence of 2/100. Vascular compression from an artery at the root entry zone, tumor involvement, and development of a plaque can cause trigeminal neuralgia, which is likely an ephaptic transmission in the nerve from demyelinated pain fibers. Of note, there is no correlation of TN with herpes zoster infection, as the pain with herpes zoster is constant and not paroxysmal.

Once determined to be the cause of a patient’s pain, multiple therapies are available. Medical therapy is usually with carbamazepine, baclofen, and/or gabapentin. Nearly 70% of patients will have complete or tolerable relief with medications. Surgical options include
nerve blocks or ablations, percutaneous rhizotomy with radiofrequency or glycerol, microvascular decompression (MVD), nerve sectioning, and stereotactic radiosurgery. MVD is the most durable treatment providing sustained relief at ten years in 70% of patients treated.

The incidence of facial anesthesia is reduced compared to percutaneous rhizotomy. This does require surgery, however, and the inherent risks that go along with the procedure including CSF leak and aseptic meningitis. Patients with multiple sclerosis that have a
plaque at the dorsal root entry zone will respond better to steretactic radiosurgery or percutaneous rhizotomy.
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