Toothache or Trigeminal Neuralgia ?
Toothache or Trigeminal Neuralgia.
Trigeminal neuralgia is a common neurologic disorder characterized by sharp electric pains in the jaw and teeth. Often mistaken for tooth aches trigeminal neuralgia is diagnosed after multiple dental visits and failed procedures. Patients will change dentists multiple times before finally being referred to a neurologist who is experienced in making the diagnosis of TN.
As the name suggests it involves neuralgic pain in the distribution of the trigeminal nerve or Vth cranial nerve. Most often affecting one or two of the main branches that supply the cheek (second branch or V2 maxillary branch) or the lower jaw ( third branch V3 or mandibular branch) and rarely in atypical TN the first branch or V1 ( ophthalmic branch) the pain cab be unbearable. Short sharp bursts of pain cause the face to spasm and appear as if a tic disorder is present (hence the earlier name of painful tic or tic doloreux). The pain worsens with light touch, chewing or speaking, shaving or face washing and can often times be even triggered by the wind blowing across the cheek. The pain radiates from the ear down to the jaws usually on one side of the face. A chronic achy sensation or tingling may also persist with or without numbness.
The etiology is varied and can be due to multiple different causes including inflammation of the Vth nerve from a non infectious cause (eg sarcoidosis) or an infectious cause such as a viral infection or Lymes disease, or from loss of myelin due to a demyelinating disease such as MS, or from irritation of the nerve by compression from a nearby pulsating blood vessel or tumor, lesion, etc. Often times no cause is found.
The diagnosis is made by a neurologist and often times requires imaging including an MRI of the brain with contrast and an MRAngiogram of the head vessels to assess any aberrant blood vessels. Certain blood tests may be beneficial too including Lyme titers, inflammatory markers, and ACE levels.
Once the diagnosis is made treatment options include medications and surgical options.
Tegretol or carabamazepine, an anticonvulsant is quite effective in decreasing the pain transmission. Side effects that need monitoring include blood cell counts, liver functions and sodium levels.
Trileptal or oxcarbazepine is similar to tegretol. Less side effects are noted.
Dilantin or phenytoin another anticonvulsant can also be used.
Gabapentin or neurontin is now used quite frequently with drowsiness as the limiting side effect
Lyrica or pregabalin has also been successfully used in many patients.
Nortriptyline or amitriptyline help the dull achy pain.
Baclofen an antispasticity agent has been shown to benefit individuals with more severe pain. Drowsiness is the main side effect. Abrupt withdrawal can lead to seizures hence tapering off is recommended.
Rarely pimozide has been used with caution due to its myriad of side effects.
Pain management can prescribe opioids, and occasionally try nerve blocks.
Neurosurgery can perform surgeries if there is an aberrant vessel compressing the nerve. Microvascular decompression or rhizotomy are options. Gamma Knife radio surgery is also an option.
Discuss the above treatment plans with your physician.