Transcription:
Sudden, Extreme Face Pain: Find Out What Causes It And How To Cure It

Melanie Cole (Host): Welcome to Bryan Health Podcast. I'm Melanie Cole. And joining me to discuss trigeminal neuralgia is Dr. Steven Gogela. He's a neurosurgeon with Neurological and Spinal Surgery. Dr. Gogela, it's a pleasure to have you on with us. People have heard this term. They don't know really what it is. Can you tell us a little bit about trigeminal neuralgia, how common it is? What is it?

Dr Steven Gogela: Well, thanks for having me today. Trigeminal neuralgia is pain in the face and there can be different types of painful sensations that tend to radiate along a particular distribution of one side or the other. There are different potential causes for this and different distributions where people can hurt.

Melanie Cole (Host): So then, let's talk about that. Do we know what causes it? Is it anxiety-related? Are there triggers? Stress? Or is it neurological in nature?

Dr Steven Gogela: Well, you nailed a couple of them. Sometimes flareups do tend to happen during stressful times or times of significant inflammation. However, some of the main triggers we know of can be multiple sclerosis, pressure from tumors or other types of lesions such as that, and sometimes by vascular compression, so nerves in the brain that are getting compressed by blood vessels. Otherwise, sometimes it happens without a clear cause and people are just stuck with pain and have to figure out what to do about it.

Melanie Cole (Host): So you mentioned some of the things that we know are related, like MS. Are some people more likely to get it, Dr. Gogela? If somebody does get this facial pain and tingling, does that signal that they might possibly have MS? Can it go back and forth in diagnosis that way?

Dr Steven Gogela: Well, it is more common in somebody with multiple sclerosis, but it does not mean that somebody has multiple sclerosis, nor is it considered to be one of the primary signs of it or anything like that. It's just something that we have to have in the back of our mind if somebody has trigeminal neuralgia. It can be a first symptom or one of the early symptoms of that condition.

Melanie Cole (Host): Yeah, that's so interesting because I know there are a lot of sort of non-specific symptoms that can go with many of these diseases. So let's talk about those symptoms, this tingling, this facial pain, because there are a lot of other reasons. Dental issues. I mean, we could get facial pain for a lot of reasons. Tell us some of the specific symptoms that would send us to someone like you.

Dr Steven Gogela: So facial pain can be extremely tricky. Like you mentioned, there can be numerous different causes. There can be oral pain and some patients will come to us after they've had multiple teeth pulled, a lot of dental evaluations. There can be temporomandibular joint dysfunction, so oral maxillofacial surgeons are key in this workup as well. There can be atypical facial pain, which doesn't quite fall under this umbrella of trigeminal neuralgia. So there are multiple things for us to think about as we're working this up.

Typically, with classic trigeminal neuralgia, there is lancinating or electric-like pain that is radiating along a particular distribution in the face, one or more distributions that is flared up by different triggers. This can be brushing your teeth, cold air, wind, brushing your hair. It's usually something with touch. Sometimes people have it just with opening their mouth or chewing or things of that sort. That's the most classic form of trigeminal neuralgia.

Melanie Cole (Host): This is so interesting. I remember a time in my life when I thought that that's what I had as well. So I know that it can be quite scary and to think of the things that can go with it. Are there other symptoms, other conditions, Dr. Gogela, that mimic these symptoms, which is why it might be a little tough to diagnose.

Dr Steven Gogela: Yes. Aside from the others that I mentioned there, there are different neuropathic kind of conditions that can mimic this. But through workup and evaluations, these can typically be ferreted out.

Melanie Cole (Host): So then, tell us a little bit about what happens at diagnosis. How do you diagnose it? And if somebody is getting this facial pain and traveling and tingling, what kind of doctor do they go see? Do they start at their primary care and then get referral to a neurologist or a neurosurgeon? Tell us a little bit about diagnosis.

Dr Steven Gogela: Well, typically, you start off with anti-inflammatories just to see if you can get the inflammation to calm down. If you can get it to calm down and the flareup goes away, then you don't necessarily have to have any further workup. If it persists, then certainly seeing somebody like your primary care physician would be appropriate. There are some initial medications that they may feel comfortable prescribing or they may refer to often a neurologist, but sometimes a neurosurgeon. Either is appropriate, because either route is going to trial conservative care first.

To work it up further, typically, we start with a medication. Depending upon how worrisome the symptoms seem, we may or may not get imaging to start. There are different medications. One of the classic medications is carbamazepine or Tegratal. Oftentimes, if it is classic trigeminal neuralgia, it will respond well to Tegratal at least initially. So that can be a telltale sign as well. And then eventually, during the diagnostic work, we will get an MRI of the brain. And that's just to check for those conditions I mentioned before. So is there a tumor with compression there? Is there a plaque that would be more evident of multiple sclerosis? You know, is there some other concern? Is there a blood vessel that's clearly compressing the trigeminal nerve? Those are the questions we answer with imaging?

Melanie Cole (Host): Are there forms of therapy, Dr. Gogela, that have been shown to help? We mentioned stress and anxiety as some possible triggers. Does then therapy or even antidepressants, any of that kind of thing, does that help with this?

Dr Steven Gogela: I would say secondarily. It's not necessarily considered to be a first line treatment for trigeminal neuralgia. But certainly if somebody has significant anxiety at baseline that is not well controlled, I'm sure that could contribute. There are side effects of antianxiety-type medications that can actually be helpful in neuropathic pain conditions. We use antidepressant medications pretty frequently in the pain world. So, in that way, it could be helpful, but I'd say indirectly.

Melanie Cole (Host): And what about identifying those triggers? Is there any way to do that?

Dr Steven Gogela: Yes, that's more of a clinical factor. People just come in and they already know. If I brush my teeth or if I brush my hair or if I have cold fluid in my mouth, or if I smile, those are the things that cause attacks. And they typically begin avoiding those things in their day to day life. And it can be different for different people. Some people it's their forehead, some people it's their chin or their jawline. It just depends on the distribution of pain.

Melanie Cole (Host): And before I ask you if there are any surgical treatments, Dr. Gogela, similar to migraines, and I know these are not related. But you know, when people do get those, they go into a dark room, they sort of shut down. As we're talking about triggers, when people do suffer from trigeminal neuralgia, does it help to do that sort of thing, to sort of shut down, go into a dark quiet room? Have any of those kinds of quieting types of therapy been shown to help?

Dr Steven Gogela: Those types of environmental changes are not necessarily as effective as they are for migraines. Just avoiding the triggers is the primary way to get these attacks to calm down and then medications. Sometimes the attacks become more frequent and intense as time goes on, and that's typically when treatment is escalated.

Melanie Cole (Host): So, are there any surgical treatments then that happen for someone who is refractory to the medication for whom none of this helps?

Dr Steven Gogela: Yes. So first of all, there are multiple medications. And different meds are typically tried. Usually, those meds are escalated over time so as to avoid significant side effects. But there are three, four, five agents that are very routinely used and sometimes people get more benefit from one versus another, and it can be different from person to person. So those are always tried initially across the board.

As those doses escalate and maybe side effects from those doses become more significant or people just become more of refractory to the medications, then we have to think about, "Okay, what are the potential interventions available?" From neurosurgical literature, there are three main categories of treatment for trigeminal neuralgia with interventions. One of them is the most definitive, which is an open surgical exploration through a very small cranial opening, where we identify the trigeminal nerve, as it exits the brain stem. We dissect any blood vessels free that are putting pressure on the nerve. And then, we put pads in there often to protect the nerve from any further compression from that vasculature. That's called a microvascular decompression. And for us, that has the best longevity, the most durability, the best data for pain resolution. It's also the most invasive.

Another option is something called a percutaneous stereotactic rhizotomy, which is performed under x-ray. And it's a procedure where the nerve, the trigeminal nerve, is burnt with a radiofrequency machine at the base of the skull where it exits. That is only done at certain centers, a little bit less invasive than the open craniotomy. You're not actually all the way asleep for it, but that's another option.

Finally, Gamma Knife radiosurgery is the least invasive of these three options. It is very precise application of radiation that the patient cannot feel, targeting that trigeminal nerve after it exits the brain stem. So patients come. A frame is placed. Imaging is obtained to make sure that the guidance of that radiation is perfectly precise and then it is administered. And it usually takes about 30 minutes or so for that radiation to be administered and then folks go home. Again, you can't feel the radiation, it doesn't cause any symptoms, but that can be pretty dang good relief for people in certain cases.

Melanie Cole (Host): So many options. So Dr. Gogela, before we wrap up, if someone thinks they may have this condition of trigeminal neuralgia, what should they do? Give us your best advice for the listeners for any reduction of those triggers, who they should see, what symptoms. Just kind of summarize it all for us.

Dr Steven Gogela: If it becomes a clear pattern of facial pain, starting the workup with your primary physician is the best place to start quickly, then being evaluated by a neurologist or a neurosurgeon I guess relatively quickly would be appropriate. If medications then fail to control the symptoms, a discussion with a neurosurgeon should then be held to determine what's the best route for a particular patient. Age group, medical comorbidities, nature of the pain, all of these factors weigh in, and then we can decide together when it's appropriate to trial which one of these procedures.

Here at Bryan, actually, we have the only Gamma Knife Radiosurgical Unit in Nebraska. And it's very precise for radiation for this condition in particular, so that is an excellent option for us here in town. We're fortunate to have that. So that's the pathway to getting treatment for trigeminal neuralgia.

Melanie Cole (Host): Thank you so much, Dr. Gogela. What an excellent guest you are. Thank you for joining us and thanks to our Bryan Foundation partner, Union Bank and Trust. Please visit our website at bryanhealth.org for more information and to get connected with one of our providers.

That concludes this episode of Bryan Health Podcast. I'm Melanie Cole.