NEURALGIAS (NERVE PAIN)
Neuralgias are paroxysmal, intense intermittent pain confined to nerve branches of the head and neck that provide sensations.
There is two major neuralgia concerning to face
- Trigeminal neuralgia (Sensory nerves of the face)
- Glossopharyngeal nerve (Sensory nerves of the mouth and throat)
The trigeminal nerve is a sensory nerve of the face that innervates the scalp, face, and mouth, and damage or disease to this nerve may result in sensory loss and/or pain.
Trigeminal Neuralgia is sought to be the most intense and well-known neuralgias, which displays classical features of :
Intense sharp, stabbing sensations with or without burning pain throughout the face.
It is considered as one of the most chronic painful conditions known within the body. The pain, which is often initiated by just a light touch to an area of skin, can occur at any time without warning and depending on the severity of the condition, the frequency of the attacks can vary.
Triggering factors :
These below-mentioned activities may activate intense pain, and thus, patients automatically avoid doing such –
- Brushing the teeth
- Touching or washing the face
- Applying make-up or face cream
- Face washing
- Eating, chewing or biting into something
- Exposure to cold such as cold wind on the face or air conditioning
Risk Factors :
Sex: More in females
Age: prominent within all age ranges, but most frequently, it affects individuals over the age of 50. Approximately 70% of the patients develop neuralgia after 60 years of age. Incidence increases with age.
The condition is rare to affect people younger than 40 years old.
Characteristics of pain we ask the patient:
- Site/localization : Can the pain be localized to a specific area
- Onset Sudden or gradual. when—day/night/spontaneous?
- Characteristic of pain : Sharp, stabbing and dull ache
- Radiation: pain radiate elsewhere in the same side of face
- Associated signs and symptoms
- Timing/duration Seconds/minutes/hours? (constant, paroxysmal-recurrent and slowly/rapidly progressive)
- Exacerbating or relieving factors
- Severity : How intense the pain is
The classical symptoms of trigeminal neuralgia :
- Severe sharp shooting/ stabbing pain, that feel like an ‘electric shock’ on a specific part or wider area of the face.
- Pain usually affects only one side of the face at one time.
- Pain charactre – may last from a few seconds to several minutes.
- With or without triggers, Spontaneous attacks of pain may occur
- As time progresses, the painful attacks may increase in frequency and intensity, as time prolongs
If the patient has any of the above mentioned symptoms, it’s a clear cut diseases of neuralgia and they should consult the dentist or the surgeon for further diagnosis and treatment plan
Types of trigeminal neuralgia:
Classical: Due to vascular compression of the trigeminal nerve root, resulting in anatomical changes of the root resulting in abnormal impulses of sensations
Secondary: most common, Caused due to any major neurological disease such as a tumour of the cerebellopontine angle (TN attributed to space occupying lesions) or Multiple Scelrosis
Idiopathic: No apparent cause
The first line of treatment is pharmacological treatment. The main outcome of these patients is to treat the pain experienced and manage the symptoms. Also to eradicate these symptoms in order to improve the patient’s quality of life.
Referral to a specialist or pain service or neurologist may be necessary for better advice of the medications with clear information and given to the patient.
Carbamazepine ‘Tegretol’ is an anti-convulsant drug used primarily in the treatment of epilepsy. it is now advised as the first-line of treatment for trigeminal neuralgia in patients over 18 years of age. It is considered to be of diagnostic help if complete resolution or reduction of symptoms occurs after its use.
The following dosage guideline is advocated :
- 100 mg up to twice daily, titrated in increments of 100– 200 mg every 2 weeks until pain has been relieved
- 200 mg three of four times daily (600–800 mg daily) is seen in the majority of people to be the dosage of choice sufficient to manage pain
- 1600 mg maximum dose daily
- Once pain is in remission, the dosage should be gradually reduced to the lowest possible maintenance level or even discontinued until a further episode occurs
Kindly note, the above mentioned protocol is only for educational purpose and strict medications will be advised only based on a physician’s supervision.
Complete blood picture and liver function test are to be done prior start of the medications and to be followed up periodically to keep the levels check in the body. These drugs will definitely have its side effects and thus have to be under physician’s check.
A successful surgical intervention of TN is determined by elimination of pain. Currently available surgical options are :
- Invasive technique:
(i) Microvascular decompression
(i) Radiofrequency rhizotomy
(ii) Retrogasserian glycerol rhizotomy
(iii) Balloon compression of trigeminal nerve
(iv) Stereotactic radiosurgery—Gamma knife
- Non-invasive technique:
(i) Peripheral neurectomy
(ii) Alcohol injections
(iv) Selective radiofrequency thermocoagulation
Glossopharyngeal neuralgia (GPN) is a rare uncommon painful neuralgic condition involving pharyngeal/orofacial region including the ear, base of the tongue, tonsillar fossa and submandibular region.
It presents as a unilateral, severe and paroxysmal pain involving the ear, base of the tongue, tonsillar fossa and submandibular region. Painful symptoms are described such as, sharp, stabbing or electric shock like pain. It is triggered by innocuous stimuli/function like swallowing, chewing, talking.
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