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Trigeminal Neuralgia

5 min read

References:

  1. Brunner & Suddarth’s Textbook of Medical-Surgical Nursing, 15th Edition, ISBN 978-197-51-6103-3, by Janice L. Hinkle, Kerry H. Cheever, and Kristen J. Overbaugh ([ebook] pp. 5561-5563)
  2. Lecturer (VJVS)

Trigeminal neuralgia, formerly known as tic douloureux, is a condition of the fifth cranial nerve that is characterized by paroxysms of sudden pain in the area innervated by any of the three branches of the nerve. The pain ends as abruptly as it starts and is described as a unilateral shooting and stabbing or burning sensation. The unilateral nature of the pain is an important feature. Associated involuntary contraction of the facial muscles can cause sudden closing of the eye or twitching of the mouth, hence the former name tic douloureux (painful twitch). Tearing may also appear due to pain.

  • Although the cause is not certain, it is thought to be demyelination of axons in the trigeminal ganglion, root, and nerve by pressing vessels or a demyelinating disease such as MS.
  • Trigeminal neuralgia occurs most often as people age, most commonly between the fifth and sixth decade of life; more common in women and in people with MS, such that the appearance of trigeminal neuralgia prior age 50 should warrant an evaluation for the coexistence of MS.

Pain-free intervals should be measured in terms of minutes, hours, days, or longer. With advancing years, the painful episodes tend to become more frequent and agonizing. The patient lives in constant fear of attacks. This has resulted in a pseudonym of “suicide disease”, as individuals with this disease may experience pain that drives them to suicide.

Paroxysms can occur with any stimulation of the terminals of the affected nerve branches, such as washing the face, shaving, brushing the teeth, eating, and drinking. A draft of cold air or direct pressure against the nerve trunk may also cause pain. Certain areas are called trigger points because the slightest touch immediately starts a paroxysm or episode. To avoid stimulating these areas, patients with trigeminal neuralgia try not to touch or wash their faces, shave, chew, or do anything else that might cause an attack. These behaviors are a clue to the diagnosis.

Medical Management

Pharmacologic Therapy

  1. Anticonvulsant agents, such as carbamazepine, relieve pain in most patients with trigeminal neuralgia by reducing the transmission of impulses at certain nerve terminals.
    • Carbamazepine is taken with meals. Serum levels (normally 5 to 12 mcg/mL) must be monitored to avoid toxicity in patients who require high doses to control the pain.
    • Side effects include nausea, dizziness, drowsiness, and aplastic anemia. The patient is monitored for bone marrow depression during long-term therapy, as toxicity can result in agranulocytosis, predisposing the patient to infection.
  2. Gabapentin and baclofen are also used for pain control.
  3. If pain control is still not achieved, phenytoin may be used as adjunctive therapy.

Surgical Management

If pharmacologic management fails to relieve pain, surgical options are available. These may relieve pain for a few years, though recurrence is possible. The choice of procedure depends on the patient’s preference and health status.

  1. Microvascular Decompression of the Trigeminal Nerve: an intracranial approach to relieve the contact between the cerebral vessel and the trigeminal nerve root entry.
  2. Radiofrequency Thermal Coagulation: percutaneous radiofrequency produces a thermal lesion on the trigeminal nerve. Immediate pain relief is experienced, dysesthesia of the face and loss of the corneal reflex may occur. MRI identifies the trigeminal nerve followed by gamma knife radiosurgery (noninvasive delivery of focused radiation).
  3. Percutaneous Balloon Microcompression: a balloon is placed and filled with contrast material (both for fluoroscopic identification and compression) for 1 minute and provides microvascular decompression.

Nursing Management

  1. Preventing Pain: Preoperative management of a patient with trigeminal neuralgia occurs mostly on an outpatient basis and includes recognizing factors that may aggravate excruciating facial pain, such as food that is too hot or too cold or jarring of the patient’s bed or chair. Even washing the face, combing the hair, or brushing the teeth may produce acute pain. The nurse can assist the patient in preventing or reducing pain by providing education about preventive strategies:
    • Providing cotton pads and room temperature water for washing the face
    • Instructing the patient to rinse with mouthwash after eating if toothbrushing causes pain
    • Performing personal hygiene during pain-free intervals
    • Take soft foods and fluids at room temperature and chew on the unaffected side
    • The nurse must recognize that anxiety, depression, and insomnia often accompany chronic painful conditions and use appropriate interventions and referrals.
  2. Providing Postoperative Care: 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 the pain of a resulting injury will not be detected.
    • The eye is assessed for irritation or redness.
    • Artificial tears may be prescribed to prevent dryness in the affected eye.
    • 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 or swallowing foods of different consistency.
  3. Improve Nutritional Intake. Poor eating habits may appear due to avoidant behavior attempting to avoid the potential for a paroxysm. The nurse should present food attractively and suggest diets that help reduce the risk of pain.
    • If oral nutrition is no longer possible, enteral feedings via NGT may be used. In severe cases, parenteral nutrition may be instituted.
  4. Enhancing Hygiene: The patient, being reluctant to touch their face, may fail to perform basic hygiene. The nurse should promote or assist in maintaining hygiene.

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