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Tic doloreaux! Fun to say, no fun to have…

January 2, 2007

Hx: I was asked by a family member to put this together. She has a diabetic mother with tic doloreaux. She was put on Tegretol while already taking Neurontin for peripheral neuropathy.

General conclusions made: Diabetes could have played a part in tic doloreaux. Its especially common in women. Tegretol and Neurontin are 2 drugs that seem to do about the same thing and are totally OK together. Usually the protocol is either lots of Tegretol, lots of Neurontin, or a combo thereof, all depending on if the patient is bothered by side effects. If the drugs don’t work or the side effects are too much, surgery seems to be a pretty good route b/c you don’t have to worry about losing feeling in your face as you would with radiation. However, the orthovoltage technique is good if you are worried about surgical complications, though I don’t know where you can get this done.

1) General info about Tic Doloreaux (Trigeminal Neuralgia) I got from wikipedia

Definition: Trigeminal neuralgia, or Tic Douloureux, is a neuropathic disorder of the trigeminal nerve that causes episodes of intense pain in the eyes, lips, nose, scalp, forehead, and jaw. Trigeminal neuralgia is considered by many to be among the most painful of conditions and has been labeled the suicide disease, due to the significant numbers of people taking their own lives because they were unable to have their pain controlled with medications or surgery.

The trigeminal nerve is the fifth cranial nerve, a mixed cranial nerve responsible for sensory perception in the face above the jawline; it is also responsible for the motor function of the muscles of mastication, the muscles involved in chewing but not facial expression. The episodes of pain occur suddenly, sometimes triggered by common activities or cold exposure, and are said to feel like stabbing electric shocks. Individual attacks affect one side of the face at a time, last several seconds, and may come and go-throughout the day. Many patients describe a trigger area on the face, such that touching or even air currents can trigger an episode of pain. Although trigeminal neuralgia is not fatal, successive recurrences may be incapacitating, and the fear of provoking an attack may make sufferers reluctant to engage in normal activities.

Cause:
The main causes seem to be either the break down of nerves caused by diseases like multiple sclerosis or an abnormally coursing artery compressing the nerve. Rarely it is caused by a tumor or idiopathically (no reason).

Treatment: There is no cure for trigeminal neuralgia, but it can be treated with anticonvulsants such as carbamazepine (Tegretol), phenytoin, or gabapentin (Neurontin). Surgery may be recommended, either to relieve the pressure on the nerve or to damage it further to prevent the transmission of pain. Surgery is effective in more than 75% of people with classic trigeminal neuralgia. The nerve can also be damaged to prevent pain signal transmission using a fine beam of radiation, so-called gamma knife. This is used especially for those people who are medically unfit for a long general anaesthetic, or who are taking medications for prevention of blood clotting (e.g., warfarin). Excellent success rates using a cost effective percutaneous surgical procedure known as balloon compression have been reported. This technique has been helpful in treating the elderly for whom surgery may not be an option due to coexisting health conditions. Balloon compression is also the best choice for patients who have ophthalmic nerve pain or have experienced recurrent pain after microvascular decompression (MVD).

Microvascular Decompression Surgery: In 1934, Walter Dandy theorized that trigeminal neuralgia is caused by a blood vessel compressing the trigeminal nerve. In order to treat this, a hole about the size of a half dollar or so is cut into the skull, and the dura mater is moved aside. The offending blood vessels are moved off of the trigeminal nerve and a piece of teflon is placed between the vessel and the nerve. In contrast to the other destructive methods, excellent long-term results concerning freedom from pain, preservation of function and quality of life can be expected.

2) What my Neurology teacher added
-Usually occurs in women over age of 40
-Tends to affect cheek or chin
-Rarely occurs on both sides of face unless you have multiple sclerosis
-Pain can provoke muscle spasms
–> Caused by compression of trigeminal nerve root by torturous (knotted, wound-up) or aberrant vessels which harden and elongate with age (probably accelerated by diabetes)
–>Diabetes causes peripheral neuropathy, a derangement in the neurons, so it seems like diabetes would have a double effect to someone prone to tic doloreaux, but I’m just guessing
-Usually responsive to Tegretol, some cases require surgery

3) Tegretol info
-Tegretol (carbamazepine) is an anticonvulsants. It works by decreasing nerve impulses that cause seizures and pain. It is used to treat seizures and nerve pain such as trigeminal neuralgia and diabetic neuropathy.
-The starting daily dose is low, (one to two pills a day), which is gradually increased until the pain is completely alleviated or side effects occur.
-Carry an ID card or wear a medical alert bracelet stating that you are taking Tegretol, in case of emergency. Any doctor, dentist, or emergency medical care provider who treats you should know that you are taking Tegretol.
-Grapefruit and grapefruit juice may interact with Tegretol and cause unwanted side effects. Do not change the amount of grapefruit products in your diet without first talking to your doctor.
-It may take 4 weeks or more for you to start feeling better. Do not stop using Tegretol without first talking to your doctor. You may have unpleasant side effects if you stop taking this medication suddenly.
-Ask your doctor before taking– blood thinners, CNS depressants, Tagamet, Biaxin, Clomipramine, Corticosteroids, Delavirdine, Diltiazem, Erythromycin, Propoxyphene (e.g., Darvon), Verapamil, Estrogens, birth control pills, Quinidine, Fluvoxamine (e.g., Luvox), Isoniazid (e.g., INH), Itraconazole, Ketoconazole, MAO inhibitors, other anticonvulsants, Risperidone, or Tricyclic antidepressants
-Make sure you tell your doctor if you have any other medical problems, especially:
* Alcohol abuse (or history of)—Drinking alcohol may decrease the effectiveness of carbamazepine
* Anemia or other blood problems or
* Behavioral problems or
* Glaucoma or
* Heart or blood vessel disease or
* Problems with urination
* Diabetes mellitus (sugar diabetes)
* Kidney disease or
* Liver disease
–>For diabetic patients: Carbamazepine may affect urine sugar levels. While you are using this medicine, be especially careful when testing for sugar in your urine. If you notice a change in the results of your urine sugar tests or have any questions about this, check with your doctor.
-Two small trials have shown carbamazepine to be beneficial in the treatment of diabetic neuropathic pain. Carbamazepine shows similar clinical effect to gabapentin (Neurontin) and phenytoin (Dilantin), but there have been no head-to-head trials directly comparing these drugs. Carbamazepine is effective in the treatment of trigeminal neuralgia and may be effective for other types of neuropathic pain, but the data are limited.

4) Neurontin info

–>Neurontin does not interact with other commonly used antiseizure medications. So Tegretol probably is OK
-Antacids will decrease the amount of Neurontin that is absorbed in the stomach. Do not take Neurontin for at least 2 hours after a dose of antacid.
-Neurontin affects chemicals (GABA) and nerves in the body that are involved in the cause of seizures and some types of pain. The exact way that it works is unknown. Neurontin is used with other drugs in the treatment of some types of seizures and for the management of postherpetic neuralgia (nerve pain caused by the herpes virus or shingles). Neurontin may also be used for purposes other than those listed in this medication guide.
-Results of a national, multi-centre DPN study demonstrated that patients suffering from diabetic peripheral neuropathy experienced a significant reduction in pain after treatment with the Neurontin and that 26 percent of those patients treated with Neurontin were pain-free at the end of the trial compared to 15 percent of patients treated with placebo.

5) A different website…talks about Neurontin & Tegretol together
-Treatment is usually initiated with one drug, such as Tegretol or Neurontin. The dose is increased as needed and tolerated. If any single drug proves ineffective, alternative drugs may be tried alone or in combination with other drugs.
–>There is no known interaction of Neurontin with Tegretol or Dilantin, permitting usage of these drugs in combination with Neurontin. Medical therapy is initially effective for most patients with TN. Unfortunately, about half of TN sufferers eventually become dissatisfied with medical therapy, because of incomplete control of pain or drug-related side effects that are almost always experienced. Surgical treatments are then considered.

6) Orthovoltage stereotactic technique
-A type of radiosurgery, like the gamma knife technique I mentioned at the very beginning
-The exact mechanism of pain relief is unknown. It is thought to be a two step process. Patients report an immediate decrease in the intensity of the pain even if the attacks still occur. This is postulated to be the result of an immediate interruption of ephaptic transmission. Several weeks later there is complete cessation of the attacks. This is probably secondary to delayed demyelination injury to the nerve.
-The area is visualized with an MRI machine, then irradiated
-In the multicenter study published in 1996, 60% of the patients became pain free requiring no further medical therapy, 17% had a 50-90% reduction in pain and 9% had slight improvement. Of those that attained complete relief, only 10% had relapse of their pain.
-The overall rate of facial paresthesia is slightly higher than MVD but substantially lower than the 60-80% quoted for percutaneous procedures. Unlike traditional surgery though, gamma knife surgery does not carry the risk of infection, anesthesia complications, hematoma formation, CSF leak, facial weakness, hearing loss, and brain stem injury. There are rarely serious side effects, usually no hospital stay, the treatment is accomplished in one session and patients return quickly to normal activities. In over 30 years, more than 100,000 people have received gamma knife treatment.
-I don’t know how this compares in price to surgery, or where they perform this

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4 Comments leave one →
  1. January 17, 2007 7:31 am

    Good Trigeminal Neuralgia info is hard to find.
    Try http://www.trigeminal.org

  2. October 10, 2008 2:49 am

    October 2005, after suffering over 4 years with TN and taking all those meds, my 54 yr old Dad. First under went that procedure to have the foam put in in head with no relief at all they proceeded to go on and remove a piece of his skull we thought that was a miracle unto we seen that TN left Dad with these crippling headaches, that the later installed a enfibulator which has given some relief, now after exactly 3yrs TN has returned.

  3. Yakub permalink
    August 7, 2012 3:36 am

    I had alcohol injection in right side trigeminal nerve at the age of 17 in 1963 side effect 24×7 anasthesia dolorosa. No tegretol available in 1963 in India. I had surgery V2&V3 severed proximal to ganglion followed complete relief from pain but was left with permanent numbness in face.
    In 1974 I had TN on left side, m on tegretol & neurontin till today. Pain controlled but side effects memory loss mood swings drowsy tiredness, all better than pain.

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