The trigeminal nerve (V: anatomical reminder), the V divided into 3 territories V1, V2 and V3.
- It is most often a woman over 50, frequent around 70 years.
- The pain is systematized in 1 territory of the nerve: 10% V1, 20% V3, 40% V3 and 30% several branches.
- The pain is violent with a stupefaction of the patient, it has a dazzling character with electric shocks, flashes and sensation of stings.
- The pain is accompanied by muscular spasms of the painful hemiface (Trousseau’s tic).
- Sometimes neurovegetative signs appear on the affected side with redness and tearing (rare).
- The pain occurs in bursts lasting 1 minute and those up to ten times a day.
- There is sometimes a trigger zone that triggers crises, chewing, laughing, a touch of the wing of the nose can trigger a crisis.
- The painful period lasts from 4 to 6 weeks then a remission phase of several weeks to several months is possible.
- The evolution can be done by an increase in the number of seizures with a transition to a possible chronic form.
- The good efficacy of the treatment with carbamazepine is in favor of the essential nature of the neuralgia.
- An evolution towards a permanent painful background with burning, hypoesthesia and a decrease in sensitivity to treatment with Carbamazepine is possible. She signs nerve demyelination.
It is medical, and is based on antiepileptics in particular carbamazepine at a dose of 600 mg to 1800 mg introduced gradually.
In the event of intolerance to this treatment, other antiepileptics can be used, such as gabapentin (800 to 3600 mg at progressively increasing doses), oxcarbazepine (600 to 1200 mg). In case of failure Lamotrigine can be tried but difficult to handle. Some centers also use Baclofen (60 to 80 mg per day), as an adjuvant treatment to Tegretol and/or Trileptal, which would allow better treatment efficacy.
In the event of ineffectiveness (or failure) of medical treatment, thermolysis of the Gasserian ganglion or surgical decompression can be proposed.
Thermolysis of the Gasserian ganglion is done percutaneously and is therefore less cumbersome than surgery. On the other hand, sequelae such as hypo or anesthesia of the face are relatively frequent. A technique by compression of the lymph nodes by a balloon gives fewer sequelae but painful recurrences are more frequent.
The surgery consists of lifting the compression of the nerve by a loop of the superior cerebellar artery by interposing a Teflon plate between the nerve and the artery.
Please note that there are symptomatic forms:
To look for in young subjects (multiple sclerosis, brain tumors, shingles), do a cerebral MRI.
The rule is the absence of sensitivity disorders, otherwise a check-up in search of another pathology (Brain MRI) is necessary.
Similarly, if several areas are immediately affected, a cerebral MRI should be requested.
Other causes of symptomatic neuralgia are:
- Wallenberg syndrome.
- Cerebellopontine angle tumours.
- Neuromas or meningiomas close to Gasser’s ganglion.
- Facial trauma
- A surgery of the face injuring the nerve.
- Radiation therapy.
Treatment of symptomatic forms includes treatment of the cause, whether or not associated with antiepileptic treatment.
Do not neglect the peripheral care which can increase the sensitization of the trigeminal nerve (dental problem, disorders of the dental articulation, etc…).