The document discusses trigeminal neuralgia, a severe neuropathic pain condition affecting the fifth cranial nerve, characterized by sudden, intense facial pain. It outlines its definition, etiology, types, pathophysiology, diagnostic evaluations, and various management strategies, including medical and surgical treatments, as well as nursing management. The aim is to educate nursing students on recognizing, diagnosing, and managing this debilitating condition.

2. “Trigeminal neuralgia”
Prepared by:
Samikshya Banjara
BNS 3rd
year
14th
batch
Chitwan Medical College

3. General Objective:
At the end of this session BNS 3rd year students will be able to
explain about “trigeminal neuralgia”

4. Specific objectives
At the end of this session, students will be able to:
• define trigeminal neuralgia
• list the causes of trigeminal neuralgia
• state the classification of trigeminal neuralgia
• describe the pathophysiology of trigeminal neuralgia
• list the sign and symptoms of trigeminal neuralgia

5. Specific objectives (cont..)
• list the diagnostic evaluation of trigeminal neuralgia
• explain the management of trigeminal neuralgia
• describe the nursing management of trigeminal neuralgia
• state the complication of trigeminal neuralgia

6. Introduction
• Trigeminal neuralgia is a condition/neuropathic disorder of
fifth cranial nerve i.e characterized by paroxysm of the pain
in the area innervated by any of the three branches of
trigeminal nerve.

7. Introductions (cont..)
• The pain ends as abruptly as it starts and is describes as a
unilateral shooting and stabbing sensation.
• Associated involuntary contraction of facial muscles can
causes sudden closing or twitching of mouth.

8. Introductions (cont..)
Pain usually occurs:
• 𝑣1 =eye and forehead
• 𝑣2 =cheek, upper teeth, upper gums and nose
• 𝑣3 =lower jaw, side of tongue, lower teeth, lower gums
Thus has been described as the most painful condition known to mankind. Also
known as prosopalgia, the suicide disease, tic douloureux, fothergill’s disease,
trifacial neuralgia.

10. Definition
• According to the International Association For Study of Pain
“Trigeminal neuralgia is the sudden usually unilateral, severe
brief stabbing recurrent pain in the distribution of one or
more branches of the fifth cranial nerve”.

11. Definition (cont..)
• According to International Headache Society
“Painful, unilateral affection of the face, characterized by brief
electric shock like pain limited to the distribution of one or
more divisions of trigeminal nerve. Pain is commonly evoked
by trivial stimuli including washing, shaving, smoking,
talking, brushing but may also occur spontaneously. The pain
is abrupt in onset and terminations may remit for varying
periods”.

12. Incidence
• It estimated that 5 in every 1,00,000 people
• Peak incidence is in 50-60 yrs.
• 90% of the case occurs after age 40.
• Gender –Female: Male is 2:1.
• Right sided 56% of the time only 3% people experience pain
on both side of the face.
• Roughly 15,000 new cases annually in U.S
• Most commonly involves the
Maxillary𝑣2>Mandibular𝑣3>𝑣1Opthalmic
https://pubmed.ncbi.nlm.nih

13. Etiology
• Exact cause is idiopathic but degenerative or viral origin
suspected.
• Sex : female are more affected
• Intrinsic lesion –
gross abnormalities of axon or myelin
• Multiple sclerosis

14. Etiology (cont..)
• Extrinsic lesion
• Mechanical compression by tumors and cyst.
• Blood vessels anomalies like aneurysms and atrio -venous
malformations
• dental abscess or jaw malformation
• Inflammatory condition such as Sarcoidosis and Lyme disease
• Abnormally thickened arachnoid tissue layer of brain
• Viral etiology – herpes virus infection, syphilis

15. Classification
The International Headache Society (IHS) classifies trigeminal
neuralgia into two main categories:
• Classical trigeminal neuralgia
• Secondary trigeminal neuralgia

16. Classification (cont..)
• Classical trigeminal neuralgia:
It is also known as idiopathic or typical trigeminal neuralgia.
This type of neuralgia involves sudden, severe, electric shock like
or stabbing pain in the trigeminal nerve’s distribution areas.
It’s typically unilateral and often triggered by activities like eating,
talking or touching the face.

17. Classification (cont..)
• Secondary trigeminal neuralgia:
It is also known as atypical trigeminal neuralgia.
 This type of neuralgia typically involves a more constant,
burning, aching or squeezing pain, which may not always
strictly follow the nerve’s distribution.

18. Classification (cont..)
The pain can be more persistent and may not have the same
triggers as the typical form.
This type is associated with an underlying cause, such as
multiple sclerosis, tumors compressing the trigeminal nerve
or other structural issues affecting the nerve.

19. Pathophysiology
• The trigeminal nerve exist in the pons and merges into the
gassenar ganglion before it separates into 3 branches. Trigeminal
nerve is a largest cranial nerve and has both motor and sensory
fibers.
• It primarily affects the maxilla and mandible branches of the
nerve.

20. Pathophysiology (cont..)
• The pain occurs abruptly and lasts from few seconds to a few
minutes and can reoccur at any time. Pain typically described
as intense, piercing, burning like lightning bolt; the pain affects
only one side of the face and there are no accompanying motor
or sensory deficits in the region served by the nerve.

21. Pathophysiology (cont..)
Compression of the trigeminal nerve
Injured the nerve’s protective myelin sheath
Cause erratic and hyperactive functioning of the nerve
Pain attacks at the slightest stimulation
Hinders the nerve’s ability to shut off the pain signals

22. Sign and Symptoms
In trigeminal neuralgia the specific area on the face where the
stimuli can provoke intense pain. Common trigger zones
include:
• V1 (Ophthalmic division) : it supplies sensation to the
forehead, upper eyelid and the front of the scalp
• V2 (Maxillary division): it provides sensation to the cheek,
lower eyelid, side of the nose, upper lip, and part of the palate
• V3 (Mandibular division): it innervates the lower lip, chin,
jaw, side of the head and the front part of the ear.

23. Sign and symptoms (cont..)
• Specific area affected commonly maxillary mandibular branches are
affected, causing the symptoms in lips, cheeks, jaw and nose of the
affected side and the ophthalmic branches involve the eyes, forehead
may be affected
• Sudden severe, short duration (30 -60 sec to 2 -3 min),excruciating
pain, unilateral facial pain in the distribution of one or two branches of
trigeminal nerve

24. Sign and symptoms (cont..)
• A persistent dull ache or burning sensation with occasionally sharp come
and go pain
• Sharp, stabbing or shooting pain on one side of the face that feels series of
electric shock and lasts for second to minute.
• Immediately after the pain transient facial numbness may occur
• The first episode of pain may last for days, weeks, months and then
typically the pains stop for while

25. Sign and symptoms (cont..)
• Recurrence are unpredictable, may occur several times a day or
weeks or month in the same location for each episode.
• Easily triggered
• In extreme or chronic cases of trigeminal neuralgia: include
frozen face or masked like face arise due to prolonged pain or
muscle tension resulting from the continuous discomfort.

26. Diagnostic Evaluation
1) History Taking
• Collect the information of the patient
• Ask the past history of the patient
• Ask for any injury or trauma
• Ask the patient about the nature of the pain

27. Diagnostic Evaluation (cont..)
2) Physical Examination
• Assess the condition of the patient
• Assess the sign and symptoms of the patient
• Examine the trigeminal nerve
• Assess the sensory abnormalities such as facial muscle
strength
• Assess the reflexes such as jaw jerk reflex, corneal reflex and
other general reflexes

28. Diagnostic Evaluation (cont..)
3)Neurological Examination
• Assess the GCS of the patient
• Assess for 12th
cranial nerve
• Skull X-ray: to rule out the structural changes of the patient
4)CT scan: to assess the structure of skull and identify the abnormalities

29. Diagnostic Evaluation (cont..)
5)MRI scan: it helps to provide more detail information than
CT scan
6)Angiography: to evaluate the blood vessels
7)MRA scan: to evaluate the blood vessels in the area and
determine if any vascular compression

30. Management
The goal of managing the trigeminal neuralgia are:
• To alleviate pain and improve the quality of life
• To reduce the frequency and intensity of painful episode

31. A. Medical Management
1. Drug Therapy
Anti-seizure drugs- carbamazepine, gabapentin, lamotrigine
phenyton, valproate and pregablin.
Muscle relaxants –baclofen, clonazepam.
Tricyclic antidepressants- amitriptyline, norptyline or
carbamazepine.
 Analgesic or opioids are usually not effective in controlling
pain

32. Drug Therapy (cont..)
1st
line therapy
• Anti convulsant drugs
• Carbamazepine: 400- 800 mg/day
• Oxcarbazepine: 900-1200 mg/day
2nd
line therapy
• Lamotrigine: 150-400 mg/day
• Baclofen: 40-80 mg/day
• Phenytoin: 300-500 mg/day
3rd
line therapy
• Clonazepam
• Valporic acid : 500-1500 mg/day

33. Conservative Therapy
1. Nerve Blocking with Local Anesthesia
• Relief of pain is temporary, lasting from 6-18 months
• Complications include bruising, swelling at the site of
injection

34. Conservative Therapy (cont..)
2. Biofeedback:
• It is a non-invasive approach that may be helpful with the patient with
trigeminal neuralgia
3. Reduce stress:
• Learning relaxation technique might help individual to manage stress,
potentially reducing the intensity and frequency of trigeminal neuralgia
pain episodes

35. Conservative Therapy (cont..)
4. Developing coping strategies:
• It helps individual in understanding how their body responds
to pain and teach the method to control physiological
responses

36. Surgical Management
Microvascular decompression (Jannetta procedure)
Gamma Knife Surgery
Percutaneous Radiofrequency Rhizotomy
Glycerol Rhizotomy
Balloon Compression
Radiofrequency Thermal Lesioning

37. Surgical Management (cont..)
1.Microvascular decompression (Jannetta
procedure)
• Cranial surgery performed to find and fix an offending blood
vessel that is injuring or compressing the trigeminal nerve.

38. Surgical Management (cont..)
• This procedure involves making a small
opening in the lower back portion of the
skull, locating the blood vessel, and
inserting a small pad (Teflon sponge or
shredded Teflon) to keep the blood vessel
and nerve apart. In most cases, the
causative blood vessel is an artery.

39. Surgical Management (cont..)
2.Gamma Knife Surgery
• Gamma knife surgery is a radiosurgery and no actual incision
is made, making it the least invasive surgical option.
• Gamma knife surgery is a common procedure for patients
who cannot tolerate surgery and/or those who have
unsuccessful treatments with medications.

40. Surgical Management (cont..)
• Focused beams of cobalt-60
radiation are directed on a
particular area of the brain to cut
off the trigeminal nerve’s blood
supply, causing scarring and
death of the nerve tissue.

41. Surgical Management (cont..)
3.Percutaneous Radiofrequency Rhizotomy
• It is known as radiofrequency ablation or rhizolysis
• It is an invasive surgical procedure used to alleviate pain in certain cases
of trigeminal neuralgia.
• It’s aim is to reduce or block pain signals transmitted by the trigeminal
nerve by selectively damaging the nerve fibers responsible for
transmitting pain sensation.

42. Surgical Management (cont..)
3. Glycerol Rhizotomy
• This is a procedure in which pure anhydrous glycerol injection is
administered in the trigeminal ganglion.
• Glycerol causes nerve damage by disintegration of the nerve’s myelin
sheath. This nerve injury in turn prevents the nerve from sending pain
signals to the brain.
• The goal is to damage the nerve selectively in order to interfere with the
transmission of the pain signals to the brain.

43. Surgical Management (cont..)
4.Balloon Compression
• A large needle is inserted into the trigeminal ganglion, and a tiny
balloon is inflated at its tip with a small amount of liquid.
• The goal is to squeeze the nerve against the bony tissue and cause
enough damage to disrupt the pain signals.
• The balloon is then deflated, and the needle is removed.

44. Surgical Management (cont..)
5.Radiofrequency Thermal Lesioning
• An electrode inserted through the cheek is used to heat the nerve and
cause selective damage to stop pain signals from traveling to the brain.
• The treatment provides immediate pain relief in up to 90% of patients,
but can cause more facial numbness than the other procedures and has a
pain recurrence rate of 40% at 2 to 3 years post-surgery. If necessary, the
procedure can be repeated.

45. Nursing Management
Nursing assessment:
Take complete history of the patient, of pain, including duration, severity,
and aggravating factors.
Perform physical examination including neurological examination.
Assess for nutritional status and hydration.
Assess for anxiety and depression, including problems with sleep, social
interaction, coping ability/skills.

46. Nursing Management (cont..)
Nursing Diagnosis
Chronic pain related to trigeminal nerve compression
Imbalanced body nutrition related to pain during chewing
and eating.
Powerlessness related to lack of control over painful
episodes.

47. Nursing Diagnosis (cont..)
Ineffective individual coping related to severe pain.
Anxiety related to prognosis of disease and change in health
Self- care deficit related to pain and discomfort.
Fear related to treatment or invasive procedures

48. Nursing Diagnosis (cont..)
• Deficit knowledge related to disease condition as evidenced by
frequently asked questions
• Risk for injury to the eyes related to possible reduction in corneal
sensation
• Ineffective therapeutic regimen management related to lack of
knowledge about triggering stimulus as evidenced by patient
verbalization

49. Nursing Interventions
1.To relieve pain
• To minimize the pain episodes, review with patient potential
triggering factors and develop individual coping methods.
• Encourage patient to take medicine regularly.
• Instruct patient to avoid exposure of affected area to cold.

50. Nursing Interventions (cont..)
• Help in communication methods without pain while talking.
• Improve the quality of sleep.
• Encourage patient to keep a pain diary noting the severity and
frequency of pain.
• Serum levels must be monitored to avoid toxicity in patients who
require high doses to control the pain

51. Nursing Interventions (cont..)
2.Monitor Adequate Nutrition
• Monitor daily intake and output.
• Instruct the patient to take food and fluids at room
temperature. Avoid foods that are too cold or hot.
• Encourage to chew with the help of unaffected side.

52. Nursing Interventions (cont..)
• Have the patient consult with dietician for appropriate meal,
texture and composition.
• Encourage small frequent meals to avoid fatigue and pain.
• Advice about use of nutritional supplements as needed.
• In severe cases NG Tube feeding can be done

53. Nursing Interventions (cont..)
3.To control pain
• Teach relaxation exercises such as breathing, progressive muscle
relaxation and guided imagery to relief muscle tension
• Instruct patient to share his/her fears with family or with nurses
for relief and assurance.

54. Nursing Interventions (cont..)
• Teach patient about the disease process and it’s treatment methods.
• Instruct patients the methods to prevent environment stimulation of
pain.
• Instruct patient to inspect eye for redness and foreign body if corneal
sensation is impaired and use of eye drops as prescribed.

55. Nursing Interventions (cont..)
4.To maintain health
• Teach them about follow up visit, regular medication, and
consult if any changes in sensation on face like numb.
• Refer the patient to physiotherapy and speech therapy for
facial exercise and to improve communication

56. Nursing Interventions (cont..)
5.To maintain Hygiene
• Provide cotton pads and room temperature water for washing
the face.
• Instruct the patient to rinse mouth with mouthwash after
eating if toothbrush causes pain.

57. Nursing Interventions (cont..)
• Instruct to perform personal hygiene during pain free intervals.
• Schedule routine dental care to prevent extensive dental
treatment.
• Warm normal saline irrigation of the affected eye 2/3 times a
day is helpful in preventing corneal infection.

58. Nursing Interventions (cont..)
6.To increase control
• Support patient through treatment trials.
• Teach relaxation exercises, such as guided imagery to relieve
tension.
• Encourage participation in support groups, and facilitate a
therapeutic relationship with the health care provider

59. Nursing Interventions (cont..)
7.Post- operative management
• Postoperative neurologic assessments are conducted to evaluate the patient
for facial motor and sensory deficits in each of the three branches of the
trigeminal nerve.
• If the surgery results in sensory deficits to the affected side of the face, the
patient is instructed not to rub the eye, because pain will not be felt if there
is injury.

60. Nursing Interventions (cont..)
• The eye is assessed for irritation or redness. Artificial tears may
be prescribed to prevent dryness in the affected eye.
• The patient is cautioned not to chew on the affected side until
numbness has diminished.
• The patient is observed carefully for any difficulty in eating and
swallowing foods of different consistency.

61. Nursing Interventions (cont..)
8.To provide education
• Explain what is TN using the simple terms
• Discuss about the common triggers like chewing, speaking
and ask patient to note down the activities that precede their
pain
• Explain about the prescribed medications and their side
effects
• Demonstrate the relaxation techniques like deep breathing or
gentle facial massage

62. Nursing Interventions (cont..)
9.To prevent from eye injury
• Educate the patient about the importance of protecting their
eyes due to reduce sensation
• Advise them to avoid rubbing their eyes
• Encourage foe regular eye check up by ophthalmologist to
monitor eye health, especially due to potential corneal
sensation reduction

63. Nursing Interventions (cont..)
• Instruct patient to use lubricating eye drops as prescribed
• Instruct patient to use eye patch or shield Ø Maintain the
hygiene of the patient

64. Nursing Interventions (cont..)
10.To implement strategies to avoid or minimize triggers
• Explain the common triggers of trigeminal pain such as
eating, talking, cold air exposure
• Collaborate with the patient to identify the specific triggers
that seem to consistently precede their TN pain episodes.

65. Nursing Interventions (cont..)
• Teach the patient about the relaxation techniques and stress
management which helps to reduce the impact of triggers
• Ensure that the patient understand their prescribed
medication for TN

66. Complications
• Morbidity associated with trigeminal nerve decompression stems
from hemorrhage, infection, and possible damage to the
brainstem around the area of decompression.
• Adverse effects of surgery include : corneal anesthesia, facial
numbness outside of the trigger zone, new facial pain, facial
dysesthesias, and intracranial hemorrhage (rare).

67. Complications (cont..)
• Anesthesia dolorosa
• Facial dysesthesia
• Facial numbness
• Blurred vision or chewing problems are usually temporary

68. Prognosis
• After the initial attack, the disorder may become inactive for
months or even years.
• Over time, the attacks may become more frequent, more
easily triggered, disabling, and may eventually require long-
term medication.

69. Prognosis (cont..)
• Overall, the prognosis depends on the cause of the problem.
• If there is no underlying disease, some people find that
treatment provides at least partial relief.
• In some patients, however, the pain may become constant and
severe.

70. References
• Black, J.M., & Hinkle, J.L. (2009). Medical Surgical Nursing;
(8th
ed.). volume-2 Reed Elsevier India Pvt. Ltd.
• Mandal G.N., (2016) Text book of medical surgical nursing
(5th
ed.). Makalu publication house Dillibazzar, Kathmandu.
• Shrestha, H., Paudyal, P., & Giri, S. (2072). A textbook of
Medical Surgical Nursing I & II. 2nd (ed.), Kathmandu, Nepal:
Heritage Publishers & distributors Pvt. Ltd. 368-370.

71. References
• Smeltzer, C.S., Bare, G.B, Hinkle, L.J., & Cheever, H.K (2011).
Brunner & suddarth’s Textbook of Medical – Surgical Nursing. 12th
(ed.). Wolters Kluwer Pvt. Ltd; 1973-1975
• https://
www.ninds.nih.gov/disorders/patient-caregiver-education/fact-sheets/t
rigeminal-neuralgia-factsheet
• https
://www.aans.org/Patients/Neurosurgical-Conditions-and-Treatments/Tr
igeminal-Neuralgia