Trigeminal Neuralgia - TN
(also called, tic douloureux)
Summary
Imagine the worst funny bone pain you've ever had. Now imagine that pain happening over and over,
and it's in your face! Welcome to TN, Trigeminal Neuralgia. Rare disease, sometimes described as a
feeling of an "ice-pick" in your face, confused with dental pain, and frequently misdiagnosed.
Basis of this disease is the 5th Cranial Nerve (the Trigeminal Nerve).
1. Compression issues: enlarged artery or a tumor may be pressing against nerve.
2. Myelin Sheath issues: artery wears down Myelin sheath or Multiple Sclerosis has deteriorated sheath
causing the 5th cranial nerve to dysfunction.
Often referred to as "suicide disease" due to the difficulty living with pain, also difficulty to eliminate the
pain. In addition to pain is the debilitating factor.
Surgery can offer long-term and immediate success. Drug and drug combo's are helpful. Serverity of
treatment depends on severity of the condition.
1. Broad Classification: Neurological, Neuropathic
2. Definition:
Trigeminal neuralgia, a neurologic condition of the trigeminal nerve, characterized by paroxysms of
flashing, stabbing like pain radiating along the course of the branches of the nerve from the angle of the
jaw. It is caused by degeneration of the nerve or by pressure on it. Also called prosopalgia, tic
douloureux.
Mosby's Dictionary, 1888.
3. incidence: prev
Often in people over age 50, but it can occur at any age. The disorder is more common in women than in
men.
Rare about 15:100,000
Estimated 45,000 cases in U.S.
4. Risk factors:
Advanced age is a major risk factor. Hypertension and multiple sclerosis are also risk factors.
5. Signs and symptoms:
The disorder causes extreme, sporadic, sudden burning or shock-like face pain that lasts anywhere from a
few seconds to as long as 2 minutes per episode. The intensity of pain can be physically and mentally
incapacitating. sudden, severe, electric shock-like, stabbing pain that is typically felt on one side of the jaw
or cheek. Pain may occur on both sides of the face, although not at the same time. The attacks of pain,
which generally last several seconds and may repeat in quick succession, come and go throughout the day.
These episodes can last for days, weeks, or months at a time and then disappear for months or years. In the
days before an episode begins, some patients may experience a tingling or numbing sensation or a
somewhat constant and aching pain. The intense flashes of pain can be triggered by vibration or contact
with the cheek (such as when shaving, washing the face, or applying makeup), brushing teeth, eating,
drinking, talking, or wind exposure. The pain may affect a small area of the face or may spread. The bouts
of pain rarely occur at night, when the patient is sleeping. The attacks often worsen over time,
with fewer and shorter pain-free periods before they recur. Not fatal, but can be debilitating.
6. Pathophysiology:
1. Nerve compression:
Blood vessel or tumor pressing on the trigeminal nerve as it exits the brainstem. This compression
causes the wearing away of the protective coating around the nerve (the myelin sheath).
The blood vessel that supplies the nerve can be compressed causing dysfunction to the nerve.
2. Myelin Sheath Damage: deterioration causes the nerve to send abnormal signals to the brain.
a.Aging process, as blood vessels lengthen they can come to rest and pulsate against a nerve.
b.Multiple sclerosis, a disease caused by the deterioration of myelin throughout the body
c.Tumor: may be caused by damage to the myelin sheath by compression from a tumor.
7. medical diagnosis and Tests:
MRI can detect if a tumor or multiple sclerosis is irritating the trigeminal nerve. However, unless a tumor
or multiple sclerosis is the cause, imaging of the brain will seldom reveal the precise reason why the nerve
is being irritated. Trigeminal neuralgia is usually diagnosed based on the description of the symptoms
provided by the patient. “Disease or eelimination”.
8. Therapy:
Pharm:
a. Anticonvulsants: Carbamazepine, oxcarbazepine, phenytoin, valproic acid
b. Tricyclic Antidepressants.
c. Muscle relaxants, such as baclofen (Lioresal, Kem-stro) may also be prescribed.
Non-Pharm:
Pain management , not an effective option. Pt must rely on drugs or surgery.
Surgical:
Microvascular decompression, The surgeon moves away the vessels that are compressing the nerve
and places a soft cushion between the nerve and the vessels. Advantages :most invasive of all surgeries for
TN, but the lowest probability that pain will return. Unlike rhizotomies and neurectomies, there is usually
no numbness in the face after this surgery.
A neurectomy, cutting part of the nerve. Neurectomies may be performed by cutting branches of
the trigeminal nerve in the face. When done during microvascular decompression,
a neurectomy will cause permanent numbness. However, when the operation is performed in the
face, the nerve may grow back and in time sensation may return.
Some form of Rhizotomy, such as:
Percutaneous stereotactic rhizotomy (PSR), The surgeon passes a hollow needle through the inside
of the patient’s cheek into the trigeminal nerve fibers. A heating current goes through the needle to destroy
some of the fibers (the entire nerve is not destroyed). Advantages of this procedure: long-term pain relief,
avoids facial paralysis, preserves facial sensation.
9. Nursing Diagnosis:
Acute Pain related to irritation of trigeminal nerve
Imbalanced Nutrition: less than body requirements related to pain when chewing
Ineffective Therapeutic regimen management related to deficient knowledge regarding prevention of
stimuli that trigger pain
Mosby. Mosby's Dictionary, 2183.
12. Nursing implications:
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Implications (Tending to Nursing Diagnosis)
Be aware of the symptoms, signs of disease because of frequent differential diagnosis (ie. dental)
Offer pain-management for those who have chronic aching pain (as opposed to acute, shocking pain).
Be aware of medication types needed for treatment, medication tolerence due to long term use,
communicate with pharmacist.
Be conscious of pain triggers: touching of Pt. face, patient may mumble, and choose not to smile, or
brush teeth.
Educate Pt. regarding how to avoid common pain triggers
Monitor dietary intake, tend to malnutrition signs due to difficulty oral consumption of food and
liquids.