We Provide Innovative Treatments for Trigeminal Neuralgia

“Trigeminal neuralgia” can cause sudden and unbearable pain in the face. The pain often markedly reduces the quality of life (QOL) as the pain is exacerbated by most trivial daily activities. Because many people misperceive the pain as nasal or dental pain, there is often delay in receiving correct treatments.

What Kind of Disease Is Trigeminal Neuralgia?

Trigeminal Neuralgia pain often causes severe pain on one side of the face. The pain is so intense and uncomfortable that it is sometimes described as “the worst pain in the world” or “the queen of pain”. It often impacts patient`s quality of life and patients may not be able to carry out their daily activities to the fullest. Even during the pain-free periods, the fear of pain or the memory of the pain may interfere with the activities such as eating and washing their face.

Symptoms of Trigeminal Neuralgia

• Intense pain occurs on one side of the face.
• Pain is often triggered by daily activities, such as eating, shaving, and putting on makeup.
• There may be an area of the face that always induces the pain when pressed.
• There may alternates between periods with much pain, less pain or pain free periods.
• The duration of pain may be short, lasting from a few seconds to 2 minutes.

When a patient presents with a symptom of suspected trigeminal neuralgia, we would ask the patient about the pain and the course of the symptoms as well as performing head MRI scans to check the trigeminal nerve if necessary. The treatment methods may depend on the patient’s age and the level of pain. We offer oral medications, nerve blocks, surgical treatments and gamma knife treatments.

Unresolving Sudden Onset Intermittent Facial pain could be Trigeminal Neuralgia?

The trigeminal nerve senses facial sensations such as pain, touch and cold/heat and transmits the signals to the brain. The trigeminal nerve is divided into three branches starting from the “trigeminal ganglion” at the back of the temple. Each branch of the nerve supplies 3 facial areas namely, forehead to the upper eyelid, between the lower eyelid and the upper lip and below the lower lip.

Trigeminal neuralgia is a disease where the pain is felt in the region innervated by one of the three trigeminal nerves. Many of those cases are known to be caused by the following mechanisms: the blood vessel compresses an area of the brainstem lesion, and the pulsation of the blood vessel then stimulates the nerve, causing the pain. The pain suddenly occurs on one side of the face and often subsides within a few seconds or 2 minutes at most. If the pain persists for tens of minutes or all day, there could be other causes that are inducing the pain.

Characteristic Cyclical Pain

Trigeminal neuralgia pain is often so intense that it is sometimes called “the queen of the pain.” The pain varies depending on individuals, but the common description of the pain includes the sharp pain at the back of your teeth, stabbing pain, or lightening pain.

Most of the neuralgia occurs without any potential triggers such as brushing teeth, shaving, putting on makeup or eating. This means that it is not so uncommon for patients to find difficulties in identifying the cause or the appropriate treatment for the pain. This results in patients wasting time, for example, by visiting dentists for suspected tooth decay or visiting an otolaryngologist for suspected sinusitis. The disease often results in patients developing tremendous fear of carrying out normal daily activities and reducing their quality of life.

Another characteristic of trigeminal neuralgia is that the patients often find clear distinctions between periods of intense pain and painless periods. While the patient could remain completely asymptomatic, pain may then reappear. This results in patients developing fear of impending pain, resulting in disruption of daily life. Treatment methods for trigeminal neuralgia often comprise of radical surgery at the neurosurgery department, nerve block treatment at pain clinics or gamma knife treatment. The optimal treatment varies depending on the patients’ general condition, age, and pathology. NTT Medical Center Tokyo can perform all the treatment methods and collaborate with various clinical departments to propose the best treatment option for each patient.

~Treating the Pain That You Might Have Almost Given Up On ~
We Provide Innovative Treatments for Trigeminal Neuralgia

Is it time for you to take the next step when the drug therapy becomes ineffective?
We Interviewed Our Physicians:

 

• • When a patient visits your clinic for trigeminal neuralgia, is it common to start the general treatment with oral medication first?

 

• Dr Inoue:That is correct. Trigeminal neuralgia has periods of pain and periods of no pain at all. As this cycle is repeated, a patient will most likely start with pharmacotherapy to reduce the burden placed on the body. We often use antiepileptic drugs that suppress excessive brain stimulation and epileptic seizures for trigeminal neuralgia as our first-line treatment.
• Dr Abe:The problems occurs when a large dose of antiepileptic drugs is being prescribed because the pain would not subside. Alternatively adverse drug reactions may occur due to an increased dose of the medication, resulting in drowsiness and lightheadedness. This may increase the risk of falls and impact daily activities.
• Dr
  Akabane:You may wish to consider taking the next step of treatments if your symptoms are not suppressed even with the increased dose of antiepileptic drugs.
• Dr Inoue:Certainly, the dose of medication is a crucial guide when considering treatment methods. We do see some cases where patients continuing to experience pain even after having undergone successful surgeries, in those cohort of patients whose pain has been resistant to high dose antiepileptic drugs. If we look at the scan images of these patients, the cause of the pain has been eliminated without doubt; thus, these cases are often inconsistent with their clinical outcomes. It is possible that patients have suppressed their pain with the medications for so long that their sensation does not match the reality of a radical cure. As the Director Akabane mentioned already, if the dose of medication begins to increase, I would like patients to consider other treatment methods.

Three Clinical Departments Collaborating Together to Provide the Best Personalized Treatments for Each Patients

 

• • Those patients with suspected Trigeminal Neuralgia, Patient often access our hospital through their family physicians. Which specialty departments do they often visit?

 

• • Dr Abe:If the chief complaint is pain and the MRI shows a noticeable cause, such as nerve compression by blood vessels or tumors, the patient is often referred to the Pain or the Neurosurgical departments We often collaborate with the Gamma knife department in following cases : if the consulting department determine that the patient is too old to undergo surgery, the patient does not wish to have surgery or the patent is unable to receive nerve block treatment because of the type of oral medication prescribed.
  • Dr
    Akabane:As Dr Abe just mentioned, gamma knife treatment in trigeminal neuralgia is the last resort when the pain cannot be controlled by any other mods of treatment. Traditionally the gamma knife treatment has been mostly used for other diseases such as brain tumors and cerebrovascular malformations. However, now that the Gamma knife treatment coverage is approved under the Japanese health insurance since 2015, we can propose this treatment as a more accessible treatment option compared to before.
  • Dr Inoue:The greatest advantage of trigeminal neuralgia treatment at our hospital is that we can accept patients suffering from a wide range of conditions while proposing appropriate treatment methods from among many options. If the patient’s main concern is the impairment of QOL due to the pain, then our department may offer nerve blocks or gamma knife treatments. even if the patient has been initially referred to our Neurosurgery department the tumor treatment.

 

• • I see. It is wonderful to hear that we can offer a wide range of treatment options for patients by close collaborations between various clinical departments.

 

• Dr
  Akabane:Generally, large hospitals often have a vertical structure divided by clinical departments, which tends to slow down inter departmental collaborations. In that respect, the clinical departments in our hospital have a very flat relationship; thus, we feel free to talk to one another and are abundantly flexible in responding to a given situation.
• Dr Abe:Putting patients first, we try to be as flexible as possible. The trigeminal neuralgia pain is so strong that many patients are unable to maintain their daily lives without pain relief. Patient often says “please get rid of this pain by all means” when visiting us after hearing our reputations and we really try to do our best for those patients.

Making the Right Choice ~ Understanding the Pros and Cons of Each Treatment Methods

 

• • Can you tell us more about the different modes of treatments offered by each department?

 

• Dr Abe:The Department of Pain Clinic has been engaged in trigeminal neuralgia treatment since its establishment in 1976. The main treatment is nerve block, which relieves pain by injecting drugs. Initially, local anesthesia was used to relieve pain, but owing to its short efficacy period, we started using treatment to cauterize the nerves with neurolytic agents or radiofrequency currents.While the efficacy of these treatments typically lasts for 1–2 years, the treatment is associated with risk of developing numbness. We have therefore started using the pulsed radiofrequency method to reduce the risk of numbness by using high-frequency waves at 42°C or lower. This helps to relieve nerve pain without destroying the nerves. Our department has equipment that can provide all these treatments at a high level, enabling us to propose treatment methods suitable for each patient based on diagnostic imaging.
• Dr
  Akabane:Gamma knife treatment is a treatment method that uses gamma ray, a type of radiation. Originally, it was used as a minimally invasive treatment to shrink tumors, however the treatment is now used for trigeminal neuralgia whose pain is difficult to control with pharmacotherapy alone. It is available on Japanese insurance since 2015. The most significant advantage of gamma knife treatment is its high treatment accuracy compared with other conventional radiotherapies. Accurately irradiating the small nerves with gamma rays would be helpful in eliminating pain attacks, while we do need to pay attention to potential side effects such as numbness. I would like patients to consider this procedure particularly in those patients who are unable to undergo surgical treatment.
• Dr Inoue:Treatment we offer at our Neurosurgery department is a radical surgery in which small incisions are made just behind the ear to remove the blood vessels compressing the trigeminal nerve. For those patients who do not respond well to pharmacotherapy but are young enough to tolerate surgery or the patients whose disease is caused by a tumor, are usually the candidates for the curative treatments by surgeries. In the case of tumors where the compressing tumors are difficult to treat from the incisions behind the ear, we can perform technically more difficult surgery in which the causative tumors are removed by scraping the inner ear from the front side.

We Aim to enhance the Quality of Life without giving up on pain control.

 

• • Thank you for your explanations. Finally, would you kindly give us any messages to those people suffering from trigeminal neuralgia?

 

• Dr
  Akabane:There is almost always causes behind the pain. Please do not leave your pain untreated and ensure to make a visit to a medical institution for some advice as the tests could occasionally reveal other diseases.Many patients with trigeminal neuralgia suffer for a long time, often having already seen by the dentists or the otorhinolaryngology departments. You should suspect trigeminal neuralgia if you experience sudden, short onset unbearable pain.

  Our hospital has a full range of possible treatments for trigeminal neuralgia and can propose treatment methods tailored to the severity of the condition and the patient`s lifestyle. If you have any difficulties undergoing general anesthesia, (e.g you have other medical comorbidities or you are considered too old to undergo surgery), please discuss with your family doctor about the referrals for gamma knife treatment before visiting our hospital.

• Dr Inoue:If the cause is compression by blood vessels, we will surgically remove the cause to eliminate the pain. You should consider surgery if the pain becomes so intense that you cannot control pain with medications alone. If surgery is difficult because of your age or physical condition, we will discuss with you to identify other treatment methods available at our hospital, in order to ensure that you can live a pain-free life.
• Dr Abe:Our treatment of trigeminal neuralgia has made great progress with the recent advancement of the medical technology. The following four treatment methods are currently considered effective: pharmacotherapy, neurosurgery, gamma knife treatment, and nerve block treatment at the Pain Clinic. We will provide the most appropriate and optimum treatment based on patient`s wishes. Please consult us if you have any questions or concerns.

Treatment Available at NTT Medical Center Tokyo

Neurosurgery: Performing Surgeries with the Aim to Remove the Cause of the Pain

The department performs surgery to remove the blood vessels and tumors that is compressing the trigeminal nerve leading to the pain. An incision is made behind the ear to make a small hole in the skull to remove any blood vessels or tumors in contact with the nerve. Despite surgical risks, a major advantage of this radical treatment for trigeminal neuralgia is that the pain can be expected to disappear immediately after the surgery.

If the surgical approach from the behind the ear is difficult because of the location of the tumor or for any other reasons, we can provide treatment from the front of the ear. We will suggest surgical treatments if this is appropriate for patients based on their age and comorbidities, and in those cases where the pharmacotherapy is no longer effective has or have had repeated short-term relapses after nerve block treatment.

Pain Clinic: Aiming to reduce or eliminate pain using the state-of-the-art medical technologies and equipment.

Depending on the pain site, we inject an appropriate drug and perform nerve block treatment to suppress pain and inflammation. We consider the location of the disease and potential adverse reactions (e.g., paralysis, numbness, and discomfort), in order to choose the best treatment for each patient – the treatment options include treatment that involves thermally coagulating or radiating low-temperature high-frequency waves to the nerve.

By using the medical experience accrued over the long history of the Department of Pain Clinic, we aim to reduce pain, the chief complaint of patients with trigeminal neuralgia, while enhancing their Quality of life. The efficacy of one session of nerve block treatment could last about 1 year. If the drug treatment is suitable for the patient, a pain-free period can be as long as 2–5 years.

Gamma Knife Center: Potential treatments options when the other options are not feasible

We aim to eliminate pain by irradiating the affected nerve using a type of radiation called gamma ray. Originally, this procedure was developed to treat blood vessels disorders of the brain and brain tumors and the treatment was the revolutionary in that the treatment was possible without surgically opening the skull. Owing to its low invasiveness, the procedure can be used in patients who cannot be controlled by the Neurosurgery treatment or the treatment at the Pain Clinic. The treatment is therefore often appropriate for those who have difficulty undergoing surgery using the general anesthetics or those with postoperative recurrence.

Gamma knife treatment for trigeminal neuralgia has been covered by the Japanese Health insurance since 2015, making it now more accessible for patients. Patients who do not respond to the other treatments should consult their family doctor and be referred to our hospital.

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