side of the nose.

Intense pain, twitching,

TRIGEMINAL NEURALGIA grimacing, and frequent blinking and
tearing of the eye occur during the acute
attack (giving rise to the term tic). Some
Trigeminal neuralgia (tic douloureux) is patients may also experience facial
sudden, usually unilateral, severe, brief, sensory loss. The attacks are usually
stabbing, recurrent episodes of pain in the brief, lasting only seconds to 2 or 3
distribution of the trigeminal nerve. It is minutes, and are generally unilateral.
diagnosed in approximately 150,000 Recurrences, which are unpredictable,
Americans each year and is the most may occur several times a day, or weeks
commonly diagnosed neuralgic condition. or months apart. After the refractory (pain-
It is seen approximately twice as often in free) period, a phenomenon known as
women as in men. The majority of cases clustering can occur. Clustering is
(more than 90%) are diagnosed in characterized by a cycle of pain and
individuals over age 40. refractoriness that continues for hours.
The painful episodes are usually initiated
by a triggering mechanism of light touch at
a specific point (trigger zone) along the
ETIOLOGY AND distribution of the nerve branches.
PATHOPHYSIOLOGY Precipitating stimuli include chewing, tooth
brushing, feeling a hot or cold blast of air
The trigeminal nerve is the fifth cranial on the face, washing the face, yawning, or
nerve (CN V) and has both motor and even talking. As a result, the patient may
sensory branches. In trigeminal neuralgia eat improperly, neglect hygienic practices,
the sensory or afferent branches, primarily wear a cloth over the face, and withdraw
the maxillary and mandibular branches, from interaction with other individuals. The
are involved. The etiology and patient may sleep excessively as a means
pathophysiology of trigeminal neuralgia is of coping with the pain. Although this
not fully understood.2 One theory is that condition is considered benign, the
blood vessels, especially the superior severity of the pain and the disruption of
cerebellar artery, become compressed, lifestyle can result in almost total physical
resulting in chronic irritation of the and psychologic dysfunction or even
trigeminal nerve at the root entry zone. suicide
This irritation leads to increased firing of
the afferent or sensory fibers. Risk factors
are multiple sclerosis and hypertension. DIAGNOSTIC STUDIES
Other factors that may cause neuralgia
include herpesvirus infection, infection of A computed tomography (CT) scan or
the teeth and jaw, and a brainstem infarct magnetic resonance imaging (MRI) of the
brain is performed to rule out any lesions
(including multiple sclerosis), tumors, or
CLINICAL MANIFESTATIONS vascular abnormalities. A complete
neurologic assessment is done, including
The classic feature of trigeminal neuralgia audiologic evaluation. The results are
is an abrupt onset of paroxysms of usually normal.
excruciating pain described as a burning,
knifelike, or lightning-like shock in the lips,
upper or lower gums, cheek, forehead, or
foramen ovale into the
COLLABORATIVE CARE trigeminal cistern
- Percutaneous
● DRUG THERAPY radiofrequency
Antiseizure drug therapy may rhizotomy is an outpatient
reduce pain by stabilizing the procedure consisting of
neuronal membrane and blocking placing a needle into the
nerve firing. These first-line drugs trigeminal rootlets that are
include carbamazepine (Tegretol), adjacent to the pons and
oxcarbazepine (Trileptal), destroying the area by
topiramate (Topamax), means of a radiofrequency
clonazepam (Klonopin), phenytoin current. This can result in
(Dilantin), lamotrigine (Lamictal), facial numbness (although
and divalproex (Depakote). some degree of sensation
Gabapentin (Neurontin) or may be retained), corneal
baclofen (Lioresal) can be used in anesthesia, and trigeminal
combination with any of the motor weakness.3
antiseizure drugs if a single agent - Microvascular
is not effective. Tricyclic decompression of the
antidepressants such as trigeminal nerve is another
amitriptyline (Elavil) or nortriptyline commonly used procedure
(Pamelor, Aventyl) can be used to for neuralgia. It is done by
treat constant burning, or aching first performing a small
pain. Analgesics or opioids are craniotomy behind the ear
usually not effective in controlling (suboccipital craniotomy).
pain The next step involves
displacing and
● CONSERVATIVE THERAPY repositioning the blood
Nerve blocking with local vessels that appear to be
anesthetics is another treatment compressing the nerve at
option. Relief of pain is temporary, the root entry zone where it
lasting from 6 to 18 months. This exits the pons. This
treatment is usually tolerated well procedure relieves pain
by older adults. Some patients use without residual sensory
complementary and alternative loss, but it is potentially
therapies, usually in combination dangerous. Gamma knife
with drug treatment. These radiosurgery is another
techniques include acupuncture, surgical treatment that is
biofeedback, vitamin therapy, used to treat trigeminal
nutritional therapy, and electrical neuralgia. Radiosurgery
stimulation of the nerves. using a gamma knife
provides precise radiation
● SURGICAL THERAPY of the proximal trigeminal
- Glycerol rhizotomy is a nerve identified on high-
percutaneous procedure resolution imaging
that consists of an injection
of glycerol through the
should be served lukewarm and
NURSING MANAGEMENT offered frequently. When oral
intake is sharply reduced and the
1. Patients with trigeminal neuralgia patient’s nutritional status is
are primarily treated on an compromised, a nasogastric tube
outpatient basis. Assessment of can be inserted on the unaffected
the attacks, including the triggering side for enteral feedings.
factors, characteristics, frequency, 5. Appropriate teaching related to
and pain management techniques, surgical procedures depends on
helps you plan for patient care. the type of procedure planned
The nursing assessment should (e.g., percutaneous). Patients
include the patient’s nutritional need to know that they will be
status, hygiene (especially oral), awake during local procedures so
and behavior (including that they can cooperate when
withdrawal). Evaluate the degree corneal and ciliary reflexes and
of pain and its effects on the facial sensations are checked.
patient’s lifestyle, drug use, After the procedure the patient’s
emotional state, and suicidal pain is compared with the
tendencies. preoperative level. The corneal
2. Monitor the patient’s response to reflex, extraocular muscles,
drug therapy and note any side hearing, sensation, and facial
effects. Alternative pain relief nerve function are evaluated
measures, such as acupuncture frequently. If the corneal reflex is
and biofeedback, should be impaired, take special care to
explored for the patient who is not protect the eyes. This includes the
a surgical candidate and whose use of artificial tears or eye
pain is not controlled by other shields.
measures. Environmental 6. If intracranial surgery is performed,
management is essential during an general postoperative nursing care
acute period to decrease triggering after a craniotomy is appropriate.
stimuli. The room should be kept at After a percutaneous
an even, moderate temperature radiofrequency procedure, apply
and free of drafts. Many patients an ice pack to the jaw on the
prefer to carry out their own care, operative side for 3 to 5 hours. To
fearing that someone else will avoid injuring the mouth, the
inadvertently injure them. patient should not chew on the
3. Teach the patient about the operative side until sensation has
importance of nutrition, hygiene, returned.
and oral care and convey 7. Plan for regular follow-up care, and
understanding if previous oral instruct the patient on the dosage
neglect is apparent. A small, soft- and side effects of medications.
bristled toothbrush or a warm Although relief of pain may be
mouthwash assists in promoting complete, encourage the patient to
oral care. Hygiene activities are keep environmental stimuli to a
best carried out when analgesia is moderate level and to use stress
at its peak. management techniques.
4. Food should be high in protein and 8. Long-term management after
calories and easy to chew. It surgical intervention depends on
the residual effects of the
procedure. If anesthesia is present
or the corneal reflex is altered,
teach the patient to (1) chew on
the unaffected side; (2) avoid hot
foods or beverages, which can
burn the mucous membranes; (3)
check the oral cavity after meals to
remove food particles; (4) practice
meticulous oral hygiene and
continue with semiannual dental
visits; (5) protect the face against
extremes of temperature; (6) use
an electric razor; (7) wear a
protective eye shield or avoid
rubbing eyes; and (8) examine eye
regularly for symptoms of infection
or irritation