 The trigeminal nerve is a paired cranial nerve that has three major branches: the
ophthalmic nerve (V1), the maxillary nerve (V2), and the mandibular nerve (V3).
 Function: It supplies sensations to the face, mucous membranes, corneal reflex
and other structures of the head. It is the motor nerve for the muscles of
mastication and contains proprioceptive fibers.
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2
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INTRODUCTION
 Trigeminal neuralgia is a condition/neuropathic disorder of the fifth cranial
nerve that is characterized by paroxysms of pain in the area innervated by any
of the three branches of the trigeminal nerve.
 In Trigeminal neuralgia the sensory or afferent branches, primarily the maxillary
and mandibular branches are involved.
 The pain ends as abruptly as it starts and is describes as unilateral shooting or
stabbing sensation.
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 Pain usually occurs at eyes, forehead, lips, scalp and jaws.
 It has been labelled as suicide disease due to insignificant number of
people taking their own life because they are have their pain controlled by
medication or surgery.
 The condition was first described in detail in 1773 by John Fothergill
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DEFINITION
 Sudden usually unilateral, severe brief stabbing recurrent pain in the
distribution of one or more branches of 5TH cranial nerve.
- International association for study of pain
 Painful, unilateral affection of the face, characterized by brief electric shock
like pain limited to the distribution of one or more divisions of trigeminal
nerve. Pain is commonly evoked by trivial stimuli including washing, shaving,
smoking, talking, brushing but may also occur spontaneously. The pain is
abrupt in onset and terminations may remit for varying periods.
– International Headache Society
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SYNONYMS
 Tic Douloureux
 Trifacial Neuralgia
 Fothergill’s Disease
 Prosopalgia
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EPIDEMIOLOGY
 Incidence: 5 in every 100,000
 Peak incidence: 50 to 60 years
 90% of cases occur after age 40.
 Gender Ratio: Female : Male
2:1
 Right sided 56% of the time. Only 3% of people experience pain on both
sides of face.
 Maxillary V2 > Mandibular V3 > Ophthalmic V1
 Roughly 15,000 new cases annually in The United States.
Zakrzewska JM, Hamlyn PJ In Epidemiology of Pain, 1999
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Katusic Neuroepidemiology
1991
Contd..
 Between September 2007 and April 2015, 20 patients underwent micro
vascular decompression (MVD) of Trigeminal Neuralgia at Department of
Neurosurgery, Bir Hospital.
 9 males and 11 females and age ranged from 30-70 years.
 The neuralgic pain was localized on right side in 13 patients and left on 7
patients.
 Pain distribution was on V3 in 11, V2 in 4, V2-3 in 2 and V1- 2-3 in 3 patients
respectively.
 20 patients felt pain relief immediately after procedure and 1 patients came
after 3 years with recurrent pain requiring second surgery.
Nepal Journal of Neuroscience, 2017.
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CLASSIFICATION
International Headache Society (IHS) classified TN in two types:
 Classical/ Idiopathic/Typical :
• Unilateral, severe, stabbing, shock like pain in one side of the face.
• They are abrupt in onset and termination.
 Symptomatic/ Atypical :
• Constant dull aching, burning pain that is less severe.
• Caused by demonstrable structural lesion other than vascular compression.
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RISK FACTORS
 Advanced Age : High among old people; especially between 50 to 60 years.
 Female Sex
 Multiple Sclerosis
 While the presence of these risk factors increases the likelihood of
developing TN, it is also possible for younger people or children to have TN.
 In rare cases, trigeminal neuralgia occurring in people below 50 years of age
typically involves the ophthalmic division of the trigeminal nerve (the branch
that is least involved in TN) and may cause loss of vision
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ETIOLOGY
 Usually Idiopathic
 Compression from near-by blood
vessels: Majority of TN cases occur due to
compression of the trigeminal nerve by one or
more arteries and/or veins. Large or small
blood vessels can grow over, wrap themselves
around, or combine together to squeeze the
nerve. A constant irritation to the nerve can
also occur from the pulsating action of blood
vessels.
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 Multiple sclerosis (MS): MS is a neurodegenerative and inflammatory
condition that causes breakdown of the myelin sheath around the nerves.
This loss of protective coating around the trigeminal nerve can cause
irritability to the nerve, resulting in TN as potentially an early symptom of
MS.
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 Tumor and Cysts
 Blood vessel abnormalities like Aneurysms and Ateriovenous malformations
 Viral etiology: Herpes virus infection, Syphilis
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 Dental Etiology: It is possible that certain dental procedures or fillings may
trigger an already developing TN to suddenly become fully noticeable.
 Abnormally thickened arachnoid tissue layer of the brain
 Trauma
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 Inflammatory conditions such as sarcoidosis and Lyme disease or
vascular diseases such as scleroderma and systemic lupus
erythematous.
 Atypical TN is presumed to be caused by tumors or cysts. Typical TN
with symptoms on both sides of the face is also believed to commonly
have a cancerous origin.
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PATHOPHYSIOLOGY
Compression of the Trigeminal nerve
Injure the nerve’s protective myelin sheath
Cause erratic and hyperactive functioning of the
nerve
Pain attacks at the slightest stimulation
Hinder the nerve’s ability to shut off the pain
signals
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SIGNS AND SYMPTOMS
Severe pain:
 Sharp, stabbing, or shooting pain, on one side of the face that feels like a series
of electric shocks and lasts for seconds to minutes in typical TN
 A persistent dull ache or burning sensation with occasionally sharp come-andgo pains are common in atypical TN.
 Severe, sudden, short-duration (30–60 seconds to 2-3 min),excruciating pain,
unilateral facial pain in the distribution of one or two branches of the trigeminal
nerve (commonly V2 and V3).
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• The pain intensity is highest at the start of an episode and lessens
rapidly toward the end. It starts and stops suddenly. Dominant right side
pain.
• Pain in the same location for each episode.
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Periods of relief.
 In typical TN ,pain episodes come-and-go with periods of relief
between attacks that may last for hours or days. Sometimes a
steady dull ache may be present between episodes with no
complete relief.
 In Atypical TN, The sharp pain attacks are less severe compared
to typical TN and there are also fewer or no periods of relief
between pain cycles.
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CONTD…
 Specific Areas Affected:
Commonly the maxillary and
mandibular branches are affected,
causing symptoms in the lips, cheek,
jaw, and nose of the affected side. Less
often, when the ophthalmic branch is
involved, the eyes, forehead, and
temples may be affected.
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TRIGGER ZONES
V1
V2
V3
• Supra orbital ridge
• Skin of upper lip, Cheek, Upper
gum, ala
• Lower lip, teeth, gum and jaw
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CONTD…
Easily triggered
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 During a TN attack, the pain may cause wincing on the painful side or
even a sudden head jerk.
 The affected side of the face may also have skin turn red, along with
excessive eye tearing and/or salivation.
 The repetitive cycles of pain with breaks in between can last for weeks or
months and may be followed by a long pain-free period that can last up
to a year or more.
 Extreme cases “ Frozen face” OR “ Mask like face”.
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 Impaired function of the affected body part due to pain or muscle weakness
due to motor nerve damage.
 Loss of Deep tendon reflexes and muscle mass
 Increased sensitivity of the skin or numbness of affected skin
 Depression and weight loss and occur
 Patient may frequently have unwashed or unshaven face.
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PROGRESSION OF TRIGEMINAL NEURALGIA OVERTIME
LATER IN THE COURSE OF
DISEASE
EARLY IN THE COURSE OF
DISEASE
Periods of Exacerbations
Periods of Remission
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HISTORY TAKING:




•
•
•
•
•
•
General History: triggering stimuli and site of the pain
Chief complain
History of present illness
Ask about nature of pain: Brief, paroxysmal, severe, stabbing
Onset
Location
Quality
Intensity
Frequency
Duration
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CONTD…..
 Aggravating factors
 Alleviating factors
 Ask about other neurological symptoms particularly those common like
ataxia, dizziness, focal weakness, unilateral vision changes.
 Medical History
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PHYSICAL EXAMINATION
 Neurological examination
 Trigeminal Nerve Examination
• SENSORY ASSESSMENT eg: light touch, pin prick test
• MOTOR ASSESSMENT eg : Jaw jerk reflex
• CORNEAL REFLEX
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• Checking for signs of redness in the face or eye of the affected side
• Examining parts of the face and jaw affected during the pain attacks—this
also allows the doctor to understand the branches of the trigeminal nerve
that may be affected.
• Examination of Trigger zones
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MAGNETIC RESONANCE IMAGING(MRI)
• An MRI shows a clear picture of soft tissues, such as the brain, spinal cord,
and nerves. It can help assess nerve structure and is especially useful in
determining whether TN is caused as a result of multiple sclerosis or tumors.
CT SCAN
SKULL X-RAY
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MAGNETIC RESONANCE
ANGIOGRAPHY ( MRA)
• MRA is a sensitive and specific method to diagnose TN caused by blood
vessel compression. In this technique, a dye is injected into the blood vessel
to highlight the blood flow. The presence and severity of compressions
caused by blood vessels on nerves are well defined in MRAs.
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DIFFERENTIAL DIAGNOSIS
•
•
•
•
•
•
Dental pathology
Migraine
Cluster headaches
Multiple sclerosis
Overlying aneurysm of blood vessels
Acoustic Neuroma
• Meningiomas
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PHARMACOLOGICAL MANAGEMENT
Medications are mainly used to control the pain in TN, and do not treat the
cause of TN. For this reason, medications are generally taken long-term, as
long as the underlying causes are at work.
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• Certain medicines sometimes help reduce pain and the rate of attacks.
These medicines include:
– Anti-seizure drugs (carbamazepine, gabapentin, lamotrigine, phenytoin,
valproate, and pregabalin)
– Muscle relaxants (baclofen, clonazepam)
– Tricyclic antidepressants (amitriptyline, nortriptyline, or carbamazepine)
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FIRST LINE THERAPY
 Anti convulsant drugs
 Carbamazepine: 400- 800 mg/day
 Oxcarbazepine: 900-1200 mg/day
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SECOND LINE THERAPY
Lamotrigine : 150-400 mg/day
Baclofen : 40-80 mg/day
Phenytoin : 300-500 mg/day
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THIRD LINE OF APPROACH
 Clonazepam
 Valporic acid : 500-1500 mg/day
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CONSERVATIVE THERAPY
Nerve Blocking with Local Anesthesia
Relief of pain is temporary, lasting from 6-18 months
Complications include bruising, swelling at the site of injection
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SURGICAL MANAGEMENT
Surgical and injection procedures are recommended in trigeminal
neuralgia (TN) patients with intolerable pain, after adequate treatment
with medications in various combinations and dosages have been tried
and failed.
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MICROVASCULAR DECOMPRESSION
 Cranial surgery performed to find and fix an offending blood vessel that is
injuring or compressing the trigeminal nerve.
 This procedure involves making a small opening in the lower back portion of
the skull, locating the blood vessel, and inserting a small pad (Teflon sponge
or shredded Teflon) to keep the blood vessel and nerve apart. In most cases,
the causative blood vessel is an artery.
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SUCCESS RATE 73% TO 80 % WITH PAIN FREE PERIOD UPTO 5 YEARS
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GAMMA KNIFE SURGERY
 Gamma knife surgery is a radiosurgery and no actual incision is made,
making it the least invasive surgical option. Gamma knife surgery is a
common procedure for patients who cannot tolerate surgery and/or those
who have unsuccessful treatments with medications.
 Focused beams of cobalt-60 radiation are directed on a particular area of
the brain to cut off the trigeminal nerve’s blood supply, causing scarring and
death of the nerve tissue.
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SUCCESS RATE ESTIMATED 52%-69%
WITH PAIN FREE LIVES UPTO 3 YEARS
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GLYCEROL RHIZOTOMY
 This is a procedure in which pure anhydrous
glycerol injection is administered in the
trigeminal ganglion. Glycerol causes nerve
damage by disintegration of the nerve’s
myelin sheath. This nerve injury in turn
prevents the nerve from sending pain
signals to the brain.
 The goal is to damage the nerve selectively
in order to interfere with the transmission
of the pain signals to the brain.
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BALLOON COMPRESSION
 A large needle is inserted into the
trigeminal ganglion, and a tiny
balloon is inflated at its tip with a
small amount of liquid. The goal is
to squeeze the nerve against the
bony tissue and cause enough
damage to disrupt the pain
signals. The balloon is then
deflated, and the needle is
removed.
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Success rate: 92%
Pain free upto 35 months
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RADIOFREQUENCY THERMAL
LESIONING
 An electrode inserted through the cheek is
used to heat the nerve and cause selective
damage to stop pain signals from traveling
to the brain.
 The treatment provides immediate pain
relief in up to 90% of patients, but can
cause more facial numbness than the other
procedures and has a pain recurrence rate
of 40% at 2 to 3 years post-surgery. If
necessary, the procedure can be repeated.
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ASSESSMENT
• Take complete history of the patient, of pain, including duration, severity, and
aggravating factors.
• Perform physical examination including neurological examination.
• Assess for nutritional status and hydration.
• Assess for anxiety and depression, including problems with sleep, social
interaction, coping ability/skills.
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NURSING DIAGNOSIS
Chronic pain r/t trigeminal nerve compression as
evidenced by pain scale rating.
Imbalanced body nutrition r/t pain during chewing
as evidenced by weight loss.
Ineffective individual coping r/t severe pain as
evidenced by patient’s verbalization
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NURSING DIAGNOSIS
 Deficient knowledge r/t the disease condition as
evidenced by frequently asked questions.
 Anxiety r/t the prognosis of disease and change in
health as evidenced by increased BP, insomnia and
fear of consequences.
 Ineffective management of therapeutic regimen r/t
less knowledge about prevention of stimulus
triggers as evidenced by pt’s verbalization
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NURSING DIAGNOSIS
 Fear r/t treatment or invasive procedures, sensory
impairment as evidenced by avoidance behaviour.
 Self care deficit r/t pain, discomfort as evidenced by
poor personal hygiene, disorderly appearance.
 Powerlessness related to lack of control over painful
episodes.
 Risk for injury to the eyes r/t possible reduction in
corneal sensation
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RELIEVING PAIN
• To minimize the pain episodes, review with patient potential triggering
factors and develop individual coping methods.
• Encourage patient to take medicine regularly.
• Instruct patient to avoid exposure of affected area to cold.
• Help in communication methods without pain while talking.
• Improve the quality of sleep.
• Encourage patient to keep a pain diary noting the severity and frequency of
pain.
• Serum levels must be monitored to avoid toxicity in patients who require
high doses to control the pain.
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MONITOR ADEQUATE NUTRITION
• Monitor daily intake and output.
• Instruct the patient to take food and fluids at room temperature. Avoid
foods that are too cold or hot.
• Encourage to chew with the help of unaffected side.
• Have the patient consult with dietician for appropriate meal, texture and
composition.
• Encourage small frequent meals to avoid fatigue and pain.
• Advice about use of nutritional supplements as needed.
• In severe cases NG Tube feeding can be done.
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PATIENT EDUCATION
• Teach relaxation exercises such as breathing, progressive muscle relaxation and
guided imagery to relief muscle tension
• Instruct patient to share his/her fears with family or with nurses for relief and
assurance.
• Teach patient about the disease process and it’s treatment methods.
• Instruct patients the methods to prevent environment stimulation of pain.
• Instruct patient to inspect eye for redness and foreign body if corneal sensation
is impaired and use of eye drops as prescribed.
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HEALTH MAINTAINENCE
• Teach them about follow up visit, regular medication, and consult if any
changes in sensation on face like numb.
• Refer the patient to physiotherapy and speech therapy for facial exercise
and to improve communication.
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MAINTAIN HYGIENE
• Provide cotton pads and room temperature water for washing the face.
• Instruct the patient to rinse mouth with mouthwash after eating if
toothbrush causes pain.
• Instruct to perform personal hygiene during pain free intervals.
• Schedule routine dental care to prevent extensive dental treatment.
• Warm normal saline irrigation of the affected eye 2/3 times a day is helpful in
preventing corneal infection.
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INCREASING CONTROL
• Support patient through treatment trials.
• Teach relaxation exercises, such as guided imagery to relieve tension.
• Encourage participation in support groups, and facilitate a therapeutic
relationship with the health care provider
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POST OPERATIVE MANAGEMENT
 Postoperative neurologic assessments are conducted to evaluate the patient for
facial motor and sensory deficits in each of the three branches of the trigeminal
nerve.
If the surgery results in sensory deficits to the affected side of the face, the
patient is instructed not to rub the eye, because pain will not be felt if there is
injury.
The eye is assessed for irritation or redness. Artificial tears may be prescribed to
prevent dryness in the affected eye.
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Contd….
The patient is cautioned not to chew on the affected side until
numbness has diminished.
The patient is observed carefully for any difficulty in eating and
swallowing foods of different consistency.
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COMPLICATIONS
• Morbidity associated with trigeminal nerve decompression stems from
hemorrhage, infection, and possible damage to the brainstem around the area
of decompression.
• Adverse effects of surgery include corneal anesthesia, facial numbness outside
of the trigger zone, new facial pain, facial dysesthesias, and intracranial
hemorrhage (rare).
• Anesthesia dolorosa
• Facial dysesthesia , facial numbness
• Blurred vision or chewing problems are usually temporary
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PROGNOSIS
 After the initial attack, the disorder may become inactive for months or even
years.
 Over time, the attacks may become more frequent, more easily triggered,
disabling, and may eventually require long-term medication.
 Overall, the prognosis depends on the cause of the problem.
 If there is no underlying disease, some people find that treatment provides at
least partial relief.
 In some patients, however, the pain may become constant and severe.
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REFERENCES
• Cheever. Brunner & Suddarth's Textbook of Medical-surgical Nursing.
Edition 10th
• https://www.pain-health.com/conditions/facial-pain
• https://www.ninds.nih.gov/disorders/patient-caregivereducation/fact-sheets/trigeminal-neuralgia-fact-sheet
• https://www.aans.org/Patients/Neurosurgical-Conditions-andTreatments/Trigeminal-Neuralgia
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