Trigeminal neuralgia is a very painful condition associated with sudden severe shocks over the face and Pain. It may also be associated with inability to open the mouth during an acute attack. The attacks may be repetitive, depending on the severity and last a few seconds, but the intensity of pain is such that it is a dreaded disease. It is considered to be a problem of the trigeminal nerve due to pressure on the nerve along its course in the brain from midbrain to its exit from the skull through three nerve foraminae. Classically, it has been divided into three areas over the face. The ophthalmic division involvement produces pain and shocks around the eyes and forehead and is called V1 distribution. When pain is over the cheekbones and temple or mid half of the face is called V2 or maxillary distribution and the most common is V3 over the lower half of the face in the distribution of the mandibular nerve. A patient may have pain in one or more areas. The pain of trigeminal neuralgia may be triggered by just a touch or breeze over the face, speech or eating, brushing the teeth, et cetera.
MRI is usually indicated to rule out any pressure on the nerve in its intra cranial course by arteries or major veins. The current treatment focuses on medical management with medicines that suppress the overactivity in the nerve and painkillers. In addition, the most commonly used medication is carbamazepine ( Tegretol or Mazetol) which was originally introduced as an anti convulsant medication. It suppresses the excessive firing of the trigeminal nerve to prevent the pain. When medications are no longer effective interventions may be indicated. These interventions may take the form of simple injections of local anaesthetic and steroid or decompression of the nerve with a Fogarty catheter or radio frequency ablation of the trigeminal ganglion . Even a drastic treatment such as ablation of the nerve or its burning at 70°C is justified because of the severity of this pain. If these treatments prove to be ineffective, surgery may be indicated to relieve the pressure on the nerve by blood vessels.
All these interventions be it radio frequency, ablation or surgery carry their own risks and benefits, the risk with radio frequency ablation is that of Cornel anaesthesia or loss of sensation over the cornea of the eye, leading to ulcer on the cornea, loss of sensation over one half of the face and sometimes abnormal twitches over one half of the face. The surgery is quite safe but involves a major intracranial surgery with all the attendant complications. There are reports of failure interventions and surgery as well.
At Ashirvad we look at trigeminal neuralgia from very different perspective because we have come to understand that the pains associated with trigeminal neuralgia are actually because of trigeminal neuromyalgia involving not only the nerve but also the muscles of mastication that are involved in jaw movements during eating and speech. These muscles (masseter, temporalis , digastric medial and lateral pterygoid and mylohyoid ) receive their nerve supply from the third division of the trigeminal nerve called the mandibular nerve.
All the 3 divisions V1, V2, and V3 are all because of pain from these muscles. The pains of trigeminal neuralgia are because of the myofascial triggers and taut bands in these muscles. Sudden intense twitches of groups of these muscle fibres are felt as shocks. We have demonstrated with ultrasonography that when a patient complains of a shock, there is a demonstrable muscle twitch in the muscles. Relieving the taut bands and myofascial trigger points, with ultrasound guided dry needing or ultrasound guided botox injections followed by ultrasound guided dry needing relieves the pain of trigeminal neuralgia/neuromyalgia.
In patients with severe pain, we precede the ultrasound guided, dry needling with pulsed radio frequency of the mandibular nerve. This pulse radio frequency is carried out at 40 or 42° without any damage to the nerve, unlike the thermal ablation, which burns the nerve at 60 or 70°C. We have been using this treatment since 2006 with wonderful outcomes. We have also published an article in the journal Post graduate journal of medicine. The advantages of this approach is that there is no nerve damage nor is it a very major procedure and ultrasound guided dry needling is extremely safe albeit requiring a high degree of skill. After this treatment, most of our patients go into remission and are able to go off their medications, though some of them may require medication still, but at a much reduced dose. They also know that if they get any symptoms again, they just have to come for a few sessions of ultrasound guided dry needling to become normal again. Thus, Ashirvad approach to trigeminal neuralgia provides a user-friendly treatment that is reliable and predictable in its efficacy.
