Facial Pain Treatment, Treatment Options for Trigeminal Neuralgia

Hello, I’m Dr. Steven Bailey, and I am a neurosurgeon with Mayfield Brain & Spine. I would like to talk to you today about trigeminal neuralgia, a pain syndrome that can be terribly disruptive of people’s lives.

I became interested in treating trigeminal neuralgia during my training at the Medical University of South Carolina and at Mayfield Clinic. Both programs treat a great many patients with trigeminal neuralgia, and I experienced real satisfaction from helping people recover from this very painful condition. Trigeminal neuralgia is an inflammation of the trigeminal nerve, which supports sensation in the face. The condition typically affects one side of the face, and it can occur anywhere from the jaw to the forehead to the area around the eye. It typically begins with brief but very intense shocking sensations, which can be triggered by pretty innocuous activities of daily living, such as brushing one’s teeth, chewing, talking, or a draft of cold air that is hitting the face. Trigeminal neuralgia can be completely debilitating. We see people who can no longer work, who can’t carry out normal activities, who have difficulty shaving, eating or washing their face because of the pain. Trigeminal neuralgia can be associated with a few diseases, such as multiple sclerosis, but in most cases it is idiopathic, which means that it simply develops without known cause.

It is possible, though not proven, that genetics play a role in the origin of TN. During the early stages, trigeminal neuralgia can be managed with medications. But as time goes on, the medications can lose their effectiveness. At Mayfield, we treat patients whose trigeminal pain is no longer controlled by medications in one of three ways. The first treatment is called a microvascular decompression, or MVD. An MVD is a form of open surgery, in which an opening called a craniotomy is cut into the bony skull.

This exposes the trigeminal nerve where it leaves the brainstem. During this procedure, we look for a blood vessel that may be compressing or sitting on the nerve and causing pain. We then separate the blood vessel from the nerve and insert a cushion. The procedure is performed in the hospital, and the patient remains in the hospital several nights. The second treatment is called a percutaneous stereotactic radiofrequency rhizotomy. This is a more minimally invasive treatment, and it is performed at the Mayfield outpatient surgery center. During the procedure, I place an electrode through the skin of the cheek and into the nerve.

Our goal is to cause some controlled damage to the portion of nerve that is involved in the distribution of pain. Patients who undergo a PSR go home the same day. The third treatment involves radiation. The goal of radiation treatment is to damage the trigeminal nerve root to interrupt the pain signals and keep them from reaching the brain. Stereotactic radiosurgery is a noninvasive outpatient procedure that uses highly focused radiation beams to destroy some of the trigeminal nerve fibers that produce pain. Radiosurgery is delivered by systems such as Leksell Gamma Knife or a linear accelerator system such as the BrainLab Novalis. A stereotactic head frame or facemask is attached to the patient’s head to precisely target the nerve and to hold the head still during treatment.

Highly focused beams of radiation are delivered to the trigeminal nerve root over a period of about an hour. Pain relief may not occur immediately but rather gradually over time. A majority of patients will eventually experience improvement of their symptoms, although some may need to continue taking pain medication. Many patients are candidates for more than one type of procedure, so we take several things into consideration. These include previous treatments, any additional health conditions the patient has, and -- certainly, the patient's preference. Oftentimes the hardest part of this condition is receiving the correct diagnosis and getting to the people who are able to help you. Once patients get to the right clinical practice, like Mayfield, their trigeminal pain is quite treatable. When I see patients with trigeminal neuralgia, their biggest concern is usually, “How quickly can I get relief?” I tell them that their condition is a priority, and we will expedite their care as quickly as possible so that they can get back to enjoying life and doing all of the things they did before.

I hope this has answered your questions about how we treat trigeminal neuralgia at Mayfield. To learn more, please visit us at mayfieldclinic.com.