The evidence for Trigeminal Neuralgia non-surgical treatments

Ross Hauser, MD, Caring Medical Florida

The evidence for Trigeminal Neuralgia non-surgical treatments

In our many years helping people with chronic pain of the head, neck, jaw and face we have seen many people with a diagnosis of Trigeminal neuralgia. For some of these people, possibly including yourself, it was not easy getting this diagnosis as this problem can be confusing and frustrating to understand. Not only for the patient but the doctor alike.

Confusion surrounding Trigeminal Neuralgia is borne out by the definition of trigeminal neuralgia.

Trigeminal neuralgia means that there is nerve pain in the nerve distribution of the trigeminal nerve. It actually does not tell a person what is causing the condition.

When a physician and a patient believes that a nerve is getting compressed, it is easy to see why surgery would be recommended.

We are going to tackle a few brief learning points about Trigeminal Neuralgia and then we will learn about the treatment options. This article does present an optimistic and realistic opinion for non-surgical treatments.

Trigeminal neuralgia centers on what is happening to the trigeminal nerve which carries pain, feeling and sensation from the brain to the skin of the face. In the case of trigeminal neuralgia, most medical professionals cannot find the cause for why this pain started. This is borne out by the definition of trigeminal neuralgia. Trigeminal neuralgia means that there is nerve pain in the nerve distribution of the trigeminal nerve. It actually does not tell a person what is causing the condition.

• Many people with trigeminal neuralgia initially believed they had a serious problem with their teeth. It could have started one day when they are brushing their teeth and suddenly they had a shooting pain in their face/mouth. Some thought they even had an abscess and went to the dentist, the dentist could not find anything.
• For some, the dentist visit caused the trigeminal neuralgia
• The thought of teeth causing the problem is advanced by the fact that the pain a sufferer feels is isolated to one part of the face and is most pronounced in the jaw, teeth, gum, and cheek.

Other related causes

Trigeminal Neuralgia can also be caused by simple daily acts.

• Washing your face, shaving, the application of make up.
• Chewing food
• Talking
• Blowing your nose

The problems you were facing and why you are seeking medical care.

Is this you?

• You have a severe toothache like pain that comes and goes. This pain can last a few seconds or a few minutes.
• This on and off pain can bother you for days or weeks and suddenly go away. Then it can return and the cycle repeats.
• This problem is getting progressively worse.

Why are we examining the neck of a patient who comes in for a Trigeminal Neuralgia consultation?

The keyword is compression. The head and neck, as all parts of the body, live in a complex relation. Something in the neck can cause problems in the jaw, face, shoulders, fingers, etc. Problems in the jaw, can cause problems in the neck. Any musculoskeletal problem can cause problems of headache. Back to the keyword compression. We are looking for problems in the neck that can be influencing problems of the head and jaw. When a physician and a patient believes that a nerve is getting compressed, it is easy to see why a surgery would be recommended. Unfortunately, when cervical neck instability is the cause of the neuralgia, the surgery does not help relieve the pain.

Cervical instability can also be responsible for almost all painful neuralgias of the head and face including occipital and trigeminal neuralgia,  as well as structural headaches including tension, migraines and cluster. This is not a new concept for us, the examination of the cervical neck area is a crucial component of our comprehensive non-surgical Trigeminal Neuralgia program.

Nerve compression equals surgery? NO.

Blood vessels compressing the nerve can be corrected without surgery or pharmacological management

Research from university and medical researchers in India published in the October-December 2017 edition of the Asian Journal of Neurosurgery reviewed current Trigeminal Neuralgia treatment.(1) Here are highlights of their research:

• Trigeminal neuralgia is described as a sudden, severe, brief, stabbing, and recurrent pain within one or more branches of the trigeminal nerve.
  • Type 1 as intermittent and Type 2 as constant pain represent distinct clinical, pathological, and prognostic entities.
• While there are many things that may cause Trigeminal Neuralgia including nerve compression or nerve stretch injury, neurovascular conflict is the most accepted theory.
  • My comment: Neurovascular conflict is briefly defined as blood vessels compressing upon the nerves, In the description above, nerve compression, nerve stretch injury, and Neurovascular conflict, can be shown to be problems of cervical neck or jaw joint instability that can be corrected without surgery or pharmacological management. This will be discussed below.
  • We are going to briefly diverge her to interrupt with a 2006 study that will help us understand this study’s suggestion that surgery will no longer be warranted for trigeminal neuralgia. In 2006, Polish researchers wrote in the The Polish Otolaryngology that:
    • “Microvascular decompression (MVD) is a treatment of choice, based on the separation of offending (blood) vessel from the nerve. Those procedures are safe, with high rate success according to the literature ranging from 70-90%. “(2) If the surgery is so good, why not offer it immediately to these patients? The question gets more confused in 2017.
• Back to 2017 and the Indian research:
  • Carbamazepine (a powerful anticonvulsant medication to treat seizures, nerve pain, and bipolar disorder) is the drug of choice in Trigeminal Neuralgia; baclofen ( a muscle relaxant), lamotrigine (to treat seizures, nerve pain, and bipolar disorder), clonazepam (typically for anxiety and panic attacks, whose side effects include increase in suicidal tendencies) , oxcarbazepine (typically to treat epileptic seizures), topiramate (to treat seizures and migraine headaches), phenytoin (for seizures), gabapentin (for seizures and shingles), pregabalin (for nerve and muscle pain, may be offered in cases of fibromyalgia), and sodium valproate (to treat seizures, migraines, and bipolar disorder)can be used.
  • Multi drugs are useful when patients are unable to tolerate higher doses of Carbamazepine.
  • With an availability of increasing number of anticonvulsant drugs, it is likely that surgical option may not be offered for many years.1

The surgical answer? If surgery is so successful, why then subject patients to prolonged drug use as a means to delay the need for surgery?

• Back to the research: “A multidisciplinary approach using antidepressants and anti-anxiety drugs such as amitriptyline and duloxetine is needed for the management of emotional status.”1
• Botulinum toxin Type A injections may be offered before surgery or unwilling to undergo surgery, and in failed drug treatment.
• Tetracaine nerve block as an additional treatment after Carbamazepine, acupuncture and peripheral nerve stimulation can be used.1

The Indian researchers gave an exhaustive and detailed study on how to help patients with Trigeminal Neuralgia. Like many other conditions we see, surgery is thought to be a good option, but only after years of pharmacological pain management. Why not seek something more curative?

The difficulty in diagnosis and the problems of too much treatment or inappropropriate treatment was recently discussed in research by doctors in Germany at the Göttingen University Medical Center. Here they looked at oral problems.

• Trigeminal neuralgia is characterized by repetitive pain commonly triggered by chewing and manipulation of the gums.
• Due to these symptoms, patients are likely to consult their local dentist when symptoms first develop and may receive further dental evaluation and treatment before they are referred to a neurologist or neurosurgeon.
• Forty-one patients (82% of the study group) initially consulted their dentist; of these,
  • 27 patients received invasive dental treatment for the pain syndrome, including extractions, root canal treatments, and implants.
• A high percentage of patients that are surgically treated for trigeminal neuralgia consult their dentist first and receive possibly unjustified dental treatment. Differential diagnoses include odontogenic pain syndromes as well as atypical orofacial pain.
• This study acknowledges difficulties in correctly diagnosing trigeminal neuralgia, but seems to underestimate the extent.(3)

The same study looked at the surgical treatment options:

• Eighty-two percutaneous rhizotomies (destroying part of the nerve causing pain) and 33 microvascular decompressions (open brain surgery to relieve pressure on the cranial nerve) were performed in 99 trigeminal neuralgia patients. Two thirds reported being pain-free in follow up.

These are very difficult procedures and invasive procedures to get only 2 out of 3 patients pain-free. One out of three continues on with their pain.

The research on Neurectomy

Neurectomy is considered a nerve block in that it severs the nerve. In some instances, the nerve is removed completely. In March 2019, surgeons discussed neurectomy of the peripheral branches of the trigeminal nerve in the Journal of Maxillofacial and Oral Surgery. (4) Here are their findings:

“Oral and maxillofacial surgeons have traditionally employed the peripheral neurectomy in the surgical management of Trigeminal Neuralgia. . . Peripheral neurectomy in Trigeminal Neuralgia is associated with lesser quality of pain relief in comparison with central neurosurgical procedures.  . . Oral and maxillofacial surgeons must not consider the peripheral neurectomy as the first surgical option in the management of classic Trigeminal Neuralgia.”

The research on acupuncture for Trigeminal Neuralgia

In February 2019, Chinese Medical University researchers looked into the use of acupuncture for Trigeminal Neuralgia. They noted that acupuncture is increasingly used by patients with primary trigeminal neuralgia and that research was limited as to its effectiveness. They published their findings in the journal Complementary therapies in clinical practice.(5)

In this study, the researchers examined thirty-three randomized control trial studies. Their analysis demonstrated that the effect of both manual acupuncture and electro-acupuncture for improving response rate and the recurrence rate was more significant than carbamazepine (the anticonvulsant drug frequently prescribed for Trigeminal Neuralgia.)

Manual acupuncture achieved a more significant effect on alleviating pain intensity.

However, the Chinese team concluded: acupuncture might have some positive effects for Trigeminal Neuralgia. Nevertheless, the level of all evidence was low or very low. We could not yet draw a firm conclusion on the efficacy of acupuncture for Trigeminal Neuralgia.

Another new study, however, presented interested findings in The Journal of nervous and mental disease.(6) Here Chinese University hospital researchers made these observations in regard to clinical improvement of cognitive function in patients with Trigeminal Neuralgia following acupuncture treatments.

• The researchers recruited 116 patients with Trigeminal Neuralgia of an undetermined cause.
• The 116 patients were divided into two groups: acupuncture intervention group and sham/placebo control group.
• Clinical pain, cognitive function, and quality of life  were evaluated at the initial time of treatment, at the end of treatment, and 6 weeks after the treatment.
• Pain intensity, headache, and generalized body pain showed significant decrease both at the end of treatment and after 6 weeks of treatment when compared with the initial time.
• The scores of the cognitive tests showed significant improvement
• Conclusion: Acupuncture can be used as an alternative treatment to improve cognitive function and quaility of life of patients with Trigeminal Neuralgia.

A summary of treatments and a realistic outlook at success and non-successful treatments

In March 2019, in the European journal of neurology (7) research from an expanded team of European doctors lead by the  University of Copenhagen and the National Hospital for Neurology & Neurosurgery in London made these recommendations:

• For long-term treatment of Trigeminal Neuralgia we recommend carbamazepine or oxcarbazepine as drugs of first choice.
• Lamotrigine, gabapentin, botolinum toxin type A, pregabalin, baclofen and phenytoin may be used either alone or as add-on therapy.
• We recommend that patients should be offered surgery if pain is not sufficiently controlled medically or if medical treatment is poorly tolerated.
• Microvascular decompression (to remove herniation  or pressure on the trigeminal nerve  is recommended as first-line surgery in patients with classical Trigeminal Neuralgia.
• No recommendation can be given for choice between any neuroablative treatments (burning out the nerve) or between them and microvascular decompression in patients with idiopathic neuroablative treatments.
• Neuroablative treatments should be the preferred choice if MRI does not demonstrate any neurovascular contact.
• We recommend that patients are offered psychological and nursing support.

In the surgical aspect recommendations, two different types of surgery are offered. One the Microvascular decompression, is offered when the nerve is being pressed. The Neuroablative is offered when the nerve is not being pressed. At Caring Medical we believe we can present an option away from surgery with Prolotherapy injections because we suspect many patients can  be helped non-surgically with Prolotherapy treatments.

Case of trigeminal neuralgia helped with Prolotherapy injections

At this point, we are going to look at Prolotherapy injections as a treatment option. Prolotherapy injctions is one of the simplest treatments available for trigeminal neuralgia. A simple sugar, dextrose is injected into the jaw area to strengthen the connective tissues of the jaw joint and the cervical vertabrae. 

In cases of trigeminal neuralgia, there is often an undiagnosed ligament laxity either in the neck or the temporomandibular joint (TMJ) causing referral pain patterns that create symptoms of trigeminal neuralgia.

In this case:

• The patient is a 77 year-old-woman diagnosed with trigeminal neuralgia and as with most people with this pain, no one could determine the cause. She had struggled with this pain for five years.

Previous treatments included six root canals and acupuncture yet her pain remained. A friend referred her to Caring Medical for Prolotherapy.

During the patient’s first visit she explained that her greatest pain came with eating, talking and smiling. Often pain would shoot from her lips to her ears.

Dr. Hauser examined the patient’s TMJ and face and determined she would be a good candidate.

• Her first treatment consisted of the nerve block to her sphenopalatine ganglion (a group of nerves located in the head, just above the nose) and four dextrose Prolotherapy injections to her left TMJ.

One month later the patient returned and reported that her face was no longer painful to the touch and she no longer had shooting pain from her lips to her ear. She had some pain with talking and eating but was hopeful that the next scheduled treatments would alleviate these problems.

Researching Prolotherapy for Trigeminal Neuralgia

In the Journal of Prolotherapy, our colleagues Eileen Conaway, DO and Brian Browning, DO describe a case history of a  63 year old Hispanic female.(8)

The patient was referred to their office for osteopathic evaluation and treatment for chronic neck and head pain. Among other somatic complaints, her history revealed 13 years of burning pain on the left side of the forehead and scalp.

Figure 1. Supraorbital nerve is a branch of the V1 ophthalmic division of the trigeminal cranial nerve (CN V). It passes through the supraorbital foramen to innervate the forehead, extending to the mid scalp.

The pattern of her pain followed the V1 nerve path (see illustration to left). The pain began after undergoing two neurosurgical procedures to repair a cerebral aneurysm.

She reported pain even to light touch of the affected areas of the scalp and was often unable to brush her hair due to the pain it caused. She had tried over the counter analgesics and tramadol-acetaminophen with little relief. She was initially treated with osteopathic manipulation which provided symptomatic relief for a few hours. She was hesitant to try additional medications due to their side effect profile as she also suffered from hypertension, dyslipidemia, and non-insulin dependent diabetes.

She was treated with Neural Prolotherapy on three occasions. The first two injections were one week apart, and the third was 12 weeks later.

See the link above: Lyftogt Perineural Injection Treatment™ (also called Neurofascial Prolotherapy, as well as Neural Prolotherapy and Subcutaneous Prolotherapy) is a sometimes used side-by-side treatment with traditional dextrose based Prolotherapy. As these techniques work by different mechanisms they can diminish the pain of similar conditions, so they can be given together or separately. In Dextrose base Prolotherapy the ligament and tendon attachments are being treated, in Perineural Injection, the nerves are being treated.

After three treatments with Neural Prolotherapy she experienced complete resolution of her V1 branch trigeminal neuralgia. After one year, the patient reports the ability to brush her hair without pain and overall improvement in quality of life and her ability to perform activities of daily living.

Also detailed in the Journal of Prolotherapy is a case history described by Alan Itkin, PA-C, MS-4 in Treatment of Trigeminal Neuralgia Utilizing Neural Prolotherapy: A Case Report.(9)

• A 70-year-old male was referred by his allergist for evaluation and treatment of trigeminal neuralgia.
• The patient reported a history of facial bone fractures nearly 30 years earlier with no subsequent symptoms of trigeminal neuralgia.
• He reported having root canals complicated by infections several years prior to the onset of trigeminal neuralgia.
• His diagnosis of trigeminal neuralgia was made by a neurologist prior to being seen in our clinic.
• At the time of his initial visit, the patient was being treated with carbamazepine and lamictal.
• The patient complained of severe, sharp, stabbing pains on the right side of his face involving the mandibular, maxillary and ophthalmic branches of the trigeminal nerve. He also noted severe pain when trying to brush his teeth.

Physical:
Examination showed no focal neurologic deficits. There were dysesthesias (abnormal sensation) and allodynia (abnormal and heightened sense of pain) along the maxillary and ophthalmic branches of the trigeminal nerve.

• Throughout the visit the patient did have a characteristic “tic” every 1-2 minutes due to the pain of trigeminal neuralgia. We elected to proceed with a neural prolotherapy treatment. Prior to the procedure the patient was given a cotton swab to rub against his gums and teeth to reproduce some of his pain and sensitivity. This was done to obtain a baseline of his pain prior to the procedure.

The patient was treated utilizing a neural prolotherapy technique. Approximately 15 injections were provided to the distribution of the 3 involved branches of the trigeminal nerve.

After the procedure, the patient was instructed to utilize the cotton swab to try and reproduce his symptoms. The patient was unable to reproduce any of the pain and sensitivity that was present prior to the procedure. The patient was observed in the clinic for 15 minutes and had no “tics” from trigeminal neuralgia. The patient was instructed to follow up in 1 week however the patient did not return until 6 months later.

Six month follow up:
At this visit, the patient reported that the neural prolotherapy treatment provided him with 5 months of complete resolution of his symptoms. He stated that his symptoms only returned after hitting his head when exiting his car. His complaints at this time involved severe, sharp stabbing pain in the right forehead, right eyeball, periorbital region and right temple. He complained of pain when getting a haircut, he found that just simply touching his hair and scalp caused him severe pain.

Treatment #2:
The patient was given a second treatment of neural prolotherapy along the course of the trigeminal nerve. The same technique as the first treatment was utilized. The patient again noted an immediate, complete resolution of his pain.

Do you have questions about Trigeminal Neuralgia treatment? You can get help and information from our Caring Medical Staff.

1 Yadav YR, Nishtha Y, Sonjjay P, Vijay P, Shailendra R, Yatin K. Trigeminal neuralgia. Asian Journal of Neurosurgery. 2017 Oct;12(4):585. [Google Scholar]
2 Borucki L, Szyfter W, Wrobel M, Sosnowski P. Neurovascular conflicts. Otolaryngologia polska= The Polish otolaryngology. 2006;60(6):809-15.[Google Scholar]
3 von Eckardstein KL, Keil M, Rohde V. Unnecessary dental procedures as a consequence of trigeminal neuralgia. Neurosurg Rev. 2015 Apr;38(2):355-60; discussion 360. doi: 10.1007/s10143-014-0591-1. Epub 2014 Nov 25.[Google Scholar]
4 Yuvaraj V, Krishnan B, Therese BA, Balaji TS. Efficacy of Neurectomy of Peripheral Branches of the Trigeminal Nerve in Trigeminal Neuralgia: A Critical Review of the Literature. Journal of maxillofacial and oral surgery. 2019 Mar 1:1-8. [Google Scholar]
5 Hu H, Chen L, Ma R, Gao H, Fang J. Acupuncture for primary trigeminal neuralgia: A systematic review and PRISMA-compliant meta-analysis. Complementary therapies in clinical practice. 2018 Dec 24. [Google Scholar]
6 Gao J, Zhao C, Jiang W, Zheng B, He Y. Effect of Acupuncture on Cognitive Function and Quality of Life in Patients With Idiopathic Trigeminal Neuralgia. The Journal of nervous and mental disease. 2019 Jan.  [Google Scholar]
7. Bendtsen L, Zakrzewska JM, Abbott J, Braschinsky M, Di Stefano G, Donnet A, Eide PK, Leal PRL, Maarbjerg S, May A, Nurmikko T, Obermann M, Jensen TS, Cruccu G. EAN guideline on trigeminal neuralgia. Eur J Neurol. 2019 Mar 12. doi:10.1111/ene.13950. [Epub ahead of print] PubMed PMID: 30860637.
7 Conaway E, Browning B, Neural Prolotherapy for Neuralgia. Journal of Prolotherapy. 2014;6:e928-e931.
8 Itkin A. Treatment of Trigeminal Neuralgia Utilizing Neural Prolotherapy: A Case Report. Journal of Prolotherapy. 2016;8:e961-e965.

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