Occipital Neuralgia Causes, Symptoms, and Treatment Options Available

Occipital Neuralgia – Causes, Symptoms, and Treatment Options Available
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Hi, I'm dr. Neil Martin I'm a neurosurgeon here at UCLA and I'm chief of the department of neurosurgery

here one of the disorders that I treat on a regular basis is trigeminal neuralgia now this this is a form of facial pain

 but not everyday ordinary facial pain this is facial pain of such a severity that has been called the suicide disease

 and before we had treatments good treatments for trigeminal neuralgia in rare cases patients would commit suicide

to get away from this horrible pain what exactly distinguishes this well this is a form of pain that is sudden it is sharp

and shooting an electric shock like and it involves one side of the face it's always just one side of the face the the pain most commonly involves

what are called the first and second divisions of the trigeminal nerves divisions of the trigeminal nerve include three different divisions

the first division involves the eye and the forehead

the second division is the cheek and the third division is the jaw most often the pain starts in the third or second division and very often it starts

in a way that it seems like it's related to dental problems we've often seen people who have had multiple root canals and even tooth extractions

because the pain was suspected to be a dental problem and of course it's critically important to rule out a dental problem as the underlying cause of trigeminal neuralgia

but if if there's no dental problem if dental x-rays have been done and a patient has seen a dentist

to have everything looked at very carefully then it's not it it is the sort of pain that demands some kind of treatment

the first step in treatment is going to be medical treatment there are good medical treatments now to treat trigeminal neuralgia

 the best kind of medical treatment is usually with a medic called tegretol tegretol often will dramatically suppress the pain and completely remove it

in many people it often has to be start at a relatively low dose in rare cases tegretol can have serious side effects

so that has to be looked at initially unfortunately what we often see is that people over time have to take higher and higher doses of tegretol

 if tegretol does not work then there are other reasonably good options inc they they include lyrica and phenytoin or dilantin

so there are options in someone who has an acute severe unrelenting attack of pain in whom something has to be done immediately one of one of the inside secrets

in the treatment of trigeminal neuralgia is that an intravenous dose of dilantin can often stop the pain completely

but that has to be given in the hospital because giving in dilantin intravenously can be dangerous and less a patient is carefully monitored

but there is something that can be done for a sudden severe unrelenting attack over time a substantial proportion of patients no longer

get relief from the medication over time some patients although they're getting reasonable relief have to take such high doses of the tegretol

or dilantin or lyrica or other medications that they begin to develop side effects that are quite disabling the side effects

can include memory impairment and inability to concentrate a foggy feeling mental impairment in in extreme cases the side effects include unsteadiness walking loss of balance dizziness

 and we see a number of patients who've been on medication for years in whom the side effects have become

so unacceptable that they're looking for another alternative there are good alternatives we can go back for just a second if we good

so we mentioned that there are three divisions of the trigeminal nerve now it's important to recognize that the trigeminal nerve is largely a sensory nerve it provides sensation

to the face and it does not move the face per se there is a component of the trigeminal nerve that participates in the chewing muscle the big muscle

in your jaw and the muscle in your temporal region but facial movement is controlled by the facial nerve another one of the cranial nerves

so patients who have this sudden severe pain generally don't have any visible external evidence in terms of movement of the face what's the underlying cause

in these cases the underlying cause for most cases of trigeminal neuralgia is pressure on the trigeminal nerve

and the pressure usually occurs from a loop of a blood vessel usually one of the normal blood vessels that go to that area of the brain called

the brain stem it's often an artery called the superior cerebellar artery that's what we're seeing demonstrated here it

can be the anterior inferior cerebellar artery but what we believe happen is that as arteries elongate an elongation of arteries is something

that happens with with age a loop of the artery impinges on the nerve comes in contact with the nerve distorts it

and causes a rubbing away or a degradation of the insulation of the nerve fibers the nerve fibers short-circuit and that's

what results in the pain this electric shock like pain a bit more about the pain the pain is often triggered by certain activities touching certain areas

of the face may trigger the pain chewing eating laughing may trigger the pain in some patients the pain is

so sensitive that just a cold blast blast of wind in the face or drying one's face off after washing it is enough to trigger the pain now this this pain is not something generally that is constant 24 hours a day

 so between attacks which can last seconds or minutes patients often have no pain whatsoever those are the characteristics of trigeminal neuralgia what kind of treatment is available there are two main categories

of treatment beyond medication the cure for trigeminal neuralgia the treatment of the underlying cause involves a neurosurgical procedure called mvd microvascular decompression this is a micro neurosurgical operation

 and it involves making a small opening in the skull about the size of a quarter working through that through the surgical microscope to identify the artery that's pressing on the trigeminal nerve move it aside relieve the pressure

 and then put a pad in there so that the artery cannot return to compress again the trigeminal nerve so after doing that procedure this is what it looks like

we move the superior cerebellar artery aside that takes the pressure off the nerve and over time the nerve will heal itself the insulation of the individual nerve fibers will be restored and

the nerve function will come back to normal and the pain will end so moving the artery aside putting in a pad and we use

 we generally use a Teflon pad that's pretty inert and doesn't react with the body this is this is generally the surgical procedure involved

to treat trigeminal neuralgia in our experience more than 90% of patients experience complete or near complete relief right after the surgery

and the relief of the pain is maintained in about 65 or 75 percent of patients even out at five and ten years the goal of the treatment obviously

is complete relief of pain preservation of normal sensation in the face and the the ability to come off all medications and that successful outcome

 is what's reached in about two-thirds of patients over the long term with this kind of surgery there's no other treatment that's that effective over such a long period of time

but there are other alternatives and another very reasonable alternative is called stereotactic radiosurgery or gamma knife treatment

 and this is demonstrated here this kind of treatment involves a highly focused almost laser-like beam of radiation therapy that is directed

in an extremely accurate way to that nerve coming out of the brain now the size of that nerve really is only about a quarter of an inch it's very small smaller than a finger

but it's possible to aim the radiation therapy with that degree of precision because we can see these structures on an MRI scan

and treat it with focused radiation therapy the gamma knife unit is one that has multiple sources of radiation that are all targeted at one single spot

on the nerve the patient goes into the the unit the area of the nerve is targeted and it's radiated up to a significant dose to cause a partial radiation injury

to the nerve this does two things first it creates a certain degree of a deficit in sensation numbness in the area of the nerve of the nerve

so a small area on the face generally becomes numb in a significant proportion of patients and second the radiation effect on the nerve stimulates a healing process in the nerve that over time will restore some of the normal insulation

and relieve the pain now this kind of treatment in contrast to the surgery doesn't generally result in immediate relief of pain it generally takes three

or four weeks and sometimes longer before the radiation therapy takes effect the big advantage of focused radiation therapy

 is it does not involve any incisions it does not involve opening the bone it is not open brain surgery and a patient can be treated by this form of therapy as an outpatient

so it has very few complications the downside of the treatment is it takes a while for it to start to work about 85% of people respond to this

and have a reduction in pain or reduce their medications after treatment but over the longer term a significantly higher number of people

end up with permanent numbness of the face than with the open surgery and the pain returns in about half the people over five to ten years

 so that the long-term success rate is not quite as good there's a higher chance of having permanent numbness in the face and when

we say numbness we're talking about novocaine like numbness after you go to the dentist a wooden or dead feeling in the skin not not tingling numbness

but that lack complete lack of sensation a certain number of people up to ten percent of people actually find the numbness quite bothersome

 so that can be an undesirable side effect of the stereotactic radiosurgery so how do we select what kind of treatment for the individual patient for young healthy patients

who have severe trigeminal neuralgia there really is no better option than microvascular

decompression as long as they're willing to undergo surgery and willing to undergo the the two or three day hospitalization associated with that surgery and recover the recovery process often takes

four weeks give or take the radiation therapy is a good option for elderly patients or patients with

 significant medical problems for whom open surgery is too risky for whom anesthesia may be too risky and in those patients this outpatient therapy with very few direct side-effects is a very good

option so those are the two main areas there there are other ways of treating trigeminal neuralgia that

 involve a needle procedure through the face that either heat up the nerve or compress the nerve with a micro balloon and those can result in an immediate improvement in the facial pain they're less

stressful than open surgery but they have a significant risk of return of pain the recurrence rate is over 50% and

so the success rate over the long term is not as good as it is with the focused radiation therapy or the

gamma knife treatment as what I'd like to do at this point is take questions from the audience

so that we can make sure that we're filling in any of the gaps that that you have that relate to trigeminal neuralgia so here's the first question one patient has had trigeminal neuralgia on the right

side for 20 years and asks can it move to the left side trigeminal neuralgia from compression of one of

 the trigeminal nerves of this particular nerve only causes pain on one side of the face but it's possible to have an identical situation on the opposite side so if there's a mirror image blood vessel on the

opposite side causing compression of the other trigeminal nerve in this case the left trigeminal nerve

then it's possible to have trigeminal neuralgia on both sides but compression on one side will not give you pain on the opposite side we recently had a woman who a couple years ago had surgery on the

right side for trigeminal neuralgia she was relieved with the pain and then came back with pain on the left side it didn't respond to medication and she underwent surgery a second time on the left side another question I have bilateral trigeminal neuralgia and bilateral glossopharyngeal neuralgia and

migraines as well what's the association between migraines and trigeminal neuralgia and what is

 glossopharyngeal neuralgia trigeminal neuralgia involves pain in the areas that the trigeminal nerve

goes to that means the the jaw the cheek area and in in much less common cases in the area around the

 eye or the forehead glossopharyngeal neuralgia involves a separate nerve that provides sensation to the inside of the ear in the back of the throat

 so people with glossopharyngeal neuralgia have the same sort of sudden sharp shooting pain but that pain doesn't occur in the face or in the in the jaw or in the tongue as trigeminal neuralgia can that kind

 of pain occurs deep inside the ear or deep down in the back of the throat that sort of pain often is

caused by a similar process a blood vessel causing compression on the glossopharyngeal nerve which

is the the nerve to that goes to these different areas and it can be treated by the same sort of surgery done to move a different blood vessel away from that particular nerve it does a glossopharyngeal

neuralgia doesn't respond quite as well to medication and often requires a surgical or surgical correction now the other component of that question is what's the relationship between migraine and

 trigeminal neuralgia there's no direct biological comparison as far as we know between the two things migraine headaches don't cause trigeminal neuralgia and vice versa however it certainly is possible for

patients with trigeminal neuralgia and severe pain to experience headaches as well but those are

 secondary headaches that are a result of the severe facial pain and migraine headaches are a separate disorder that involves the brain blood vessels and other structures involving the brain the typical

migraine headache is differentiated because it's a pounding headache often associated with nausea and

 vomiting and sometimes associated with other neurological symptoms like flashing lights or hazy

vision off to one side the other neurologic consequences of migraine so the two really are different

now trigeminal neuralgia as far as we can tell doesn't seem to run in families but migraines strongly

 runs in families I've had a couple of migraine headaches my mother had migraine headaches my younger son has migraine headaches migraine headaches do tend to run in families here's a great

question are there types of trigeminal neuralgia that are better candidates for microvascular

 decompression and others that that's a great question trigeminal neuralgia does come in various types

 or at least two types one type is the classical typical type that I described that involves the sharp shooting episodes of electric shock like pain with no pain in between the episodes triggered by

touching areas of the face or eating or chewing and pay that's reliably relieved by one of the

 medications usually tegretol if the pain is of that sort then that's that's the sort of pain that is reliably

 relieved by microvascular decompression the second type of trigeminal neuralgia can have a more constant aching component that can be there all the time in addition to the sharp shooting episodes of

pain it responds less well to tegretol there may be no periods when there is no pain and this type of

 trigeminal neuralgia can also respond to microvascular decompression but it doesn't respond as

reliably so the success rate may be 85 or 90 plus percent for microvascular decompression in the classic sharpshooting episodes the success rate for this second type of trigeminal neuralgia with a

more constant pain component is really only about 50/50 trigeminal neuralgia and Lyme's disease well

Lyme's disease can have a variety of symptoms a variety of manifestations as we would say medically can cause headaches can be associated with rashes and fever it does not seem

to cause this particular kind of specific facial pain the sharpshooting electric shock type episodes that are so dramatic one other question we just just came in and that question is how is this disorder

definitely diagnosed there's no laboratory test that definitely makes the diagnosis the the diagnosis is usually made by the patient's description of their pain and it can't that diagnosis can be reinforced by doing a brain MRI scan we do a brain MRI scan not so much to see that the patient has trigeminal

 neuralgia although that diagnosis can be suggested if we see a hint of a blood vessel pressing on the

nerve but the MRI scan is actually done more to rule out other disorders of the brain that can mimic

 trigeminal neuralgia those include multiple sclerosis certain types of benign tumors even vascular malformations or aneurysms that are near the trigeminal nerve so part of the evaluation for anyone

who comes in who's going to be considered for treatment for trigeminal neuralgia is to get a brain MRI scan with a high-resolution look at the trigeminal nerve coming out of the area called the brainstem

another question uh thoughts on acupuncture as a treatment we don't have a lot of good data on the

on the short and long-term results of acupuncture treatment for trigeminal neuralgia in some patients acupuncture seems to be unusually effective for a variety of pain syndromes and I don't think it hurts

 to try acupuncture for trigeminal neuralgia we just don't know in which particular patient might be

 particularly effective at this point it's highly unlikely that's going to cause any additional problem the one problem with acupuncture if it involves any of the areas where the pain is located is that it may

actually trigger and trigger an episode so so great care has to be taken to avoid any trigger zones on the skin of the face on the side of the trigeminal neuralgia one more question my daughter suffers from

trigeminal d afferent ation pain numerous different prescriptions have been tried so what is d afferent

ation pain the afferent ation pain is pain that results from damage of some sort to the trigeminal nerve with resulting dense deep numbness of the face many years ago which we tried to treat trigeminal

neuralgia by cutting the nerve which would result in dense numbness of the entire side of the face it

would at least initially relieve the sharpshooting episodes of pain but just like phantom limb pain in a

 in a patient who's an amputee the the sense the the brain circuitry responsible for pain perception

from that side of the face somehow would become active and very often a tremendously uncomfortable sort of chronic pain syndrome would develop involving the side of the face the this

kind of pain has been called anesthesia for loss of sensation anesthesia Dolorosa Dolorosa refers to

 painful anesthesia and at this point there's no good medication that that's effective the nerve which

 has already been densely injured can't be manipulated or interacted with in any way with radiation

therapy or surgical treatment in a way that's going to affect the anesthesia Dolorosa the d afferent

ation pain currently there's some investigation going on that relates two types of brain stimulation so stimulation of pain centers in the brain with deep brain electrodes as are used to treat Parkinson's

disease offer possibly some hope for D afront ation pain cortical stimulation stimulation over the

cortex especially in the region of the the facial control zone is also something that looks promising so there are a few centers around the country with particular programs in this kind of very difficult facial pain where these kinds of electrical stimulation procedures are done now these these in these are

invasive these involve a neurosurgical procedure but there is some hope that they may offer some relief in certain cases so here's a question I've had gamma knife treatment with some success can I

repeat of the gamma knife procedure give more relief it can in some cases some people respond to a

second treatment with gamma knife and there actually are subtle variations in where the target of the

radiation therapy can be made it can be made right where they nerve comes out of the brainstem or it can be done few millimeters farther along so it may be that an additional treatment with Gamma Knife

may provide some relief and I think that's worth investigating with one's doctor you have to recognize that the risk of permanent facial numbness is going to be a bit higher with a repeat dose with

stereotactic radiosurgery with the gamma knife another question I have trigeminal neuralgia and

multiple sclerosis since 2005 and I've never had any pain relief what treatments are available for

trigeminal neuralgia associated with multiple sclerosis the the underlying problem is entirely different

multiple sclerosis is a demyelinating disease by definition the insulation on the nerve fibers is degraded in multiple sclerosis it's an autoimmune disease so the body attacks the myelin which is the

insulating material for nerve fibers the nerve fibers become exposed they cross circuit and one can get

 the pain just as one does with trigeminal neuralgia where the where the factor that that eliminates the

 appropriate insulation is the pressure from the pulsation of an artery directly next to the nerve

 so the underlying cause is different obviously microvascular decompression is not going to have any

effect on multiple sclerosis because the problem is not pressure it's a it's a problem with the actua it's

 a disease of the insulation of nerve fibers multiple the trigeminal neuralgia with multiple sclerosis can

be problematic now multiple sclerosis is sometimes resolves on its own temporarily or permanently so tiding a person over with appropriate pain relief trying the standard kinds of trigeminal neuralgia

 medications is something that can be done in a patient with multiple sclerosis if the damage to the

nerve is permanent then there is some hope that stereotactic radiosurgery may have an effect on the nerve and may provide some relief in trigeminal neuralgia due to multiple sclerosis but this this is a

 more difficult problem because it's an intrinsic disorder of the of the nerve and the nerve fibers and the insulation of the nerve fibers rather than some sort of extrinsic pressure that one can remove

surgically so one question is are there treatments that go through the upper palate instead of behind the ear the percutaneous rhizotomy is the procedure that goes through through the skin of the cheek

 and up through the soft tissue under the base of the skull so it's possible using x-ray guidance to

 place a needle through the skin all the way up to an opening in the base of the skull through which

part of the trigeminal nerve travels by introducing an electrode that can heat the nerve or a micro

catheter with a micro balloon as possible to go in and either heat the nerve would cause

pressure on the nerve and that damage often stops the pain and the damage often elicits a healing

process in the nerve that ultimately can relieve trigeminal neuralgia but as I mentioned it doesn't get to the underlying problem it doesn't do anything for the damage to the nerve that's occurring from the

pressure at the area where the nerve comes down to the brainstem so it's a palliative treatment it's an indirect treatment it's a band-aid if you will and often the pain returns after a period of time and

finally we'll take this as the last question what are my thoughts on medical marijuana as an additional supplemental treatment for the pain well marijuana works in a variety of medical disorders nausea

pain chronic pain the core treatments the fundamental treatments medically speaking for trigeminal

 neuralgia include tegretol dilantin lyrica neurontin in some cases and in general our experience relates to trying these sequentially or in combination and the majority of people get some degree of relief

with this it would not surprise me that in some patients who have incomplete relief with with these

standard medications that medical marijuana might provide some supplemental relief and we don't really know if it has any any additional benefit in some of the difficult to treat situations like

anesthesia Dolorosa the painfulness or possibly in multiple sclerosis causing trigeminal neuralgia.. Next Posts Essential Oils for Neuropathy What you Need to Know

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