Headaches due to neuralgia or neuritis

Headaches due to Neuralgia or Neuritis are severe types of intermittent pain, which are localized in the area of the affected nerve.

These conditions include trigeminal neuralgia and other conditions.

Trigeminal neuralgia

Trigeminal neuralgia is a pathological condition for which no specific cause has been established. The headache is unilateral, very intense, and recurrent, affecting the facial region.

Trigeminal neuralgia triggers pain which begins above the ear and later spreads to the entire cheek. It is a sharp, burning type of pain.

The pain can be triggered by:

• Touch
• Chewing
• Laughing
• Talking or even a cold breeze.

The pain is intermittent, can last for approximately 30 seconds, followed by a free-pain period that may reoccur for a few hours at a time.
The attacks can go for weeks or months. Attacks may at times also spontaneously subside.

Symptoms of trigeminal neuralgia

• The main symptom of trigeminal neuralgia is sudden attacks of severe sharp shooting facial pain that last from a few seconds to about two minutes. The pain is often described as excruciating, similar to an electric shock.
  The attacks can be so severe that you're unable to do anything during them.

Trigeminal neuralgia usually affects one side of the face. In rare cases, it can affect both sides, although not at the same time.

The pain can be:

• In the teeth
• Lower jaw
• Upper jaw
• Cheek
• And less commonly, in the forehead or the eye.

Symptoms that you may experience

• You may sense an attack that's about to come on, although attacks usually start unexpectedly.
• After the main severe pain has subsided, you may experience a slight ache or burning feeling.
• You may also have aconstant throbbing, aching or burning sensation between attacks.
• You may experience regular episodes of pain for days, weeks or months at a time.
  Sometimes the pain may disappear completely and not return for several months or years. This period is known as remission.

However, in severe cases of trigeminal neuralgia attacks may occur hundreds of times a day and there may be no periods of remission.

Doctor's Advice

Medical Treatment and their benefits

Medical treatment is aimed at reducing attack frequency and severity over time and is effective for approximately 70% to 80% of patients with classical Trigeminal Neuralgia.

Carbamazepine have demonstrated efficacy with 58% to 100% of patients achieving near-complete pain control and treatment response beginning as soon as 2 days after initiation.

Other RCTs have shown probable efficacy of oxcarbazepine and possible effectiveness of baclofen and lamotrigine.
Additionally, smaller studies suggest that gabapentin, valproate, and levetiracetam, as well as phenytoin and tizanidine (although both with rapidly diminishing effects over time), may have benefit in Trigeminal Neuralgia.

Type 2 Trigeminal Neuralgia

This type is less likely to respond to any of the aforementioned treatments. OnabotulinumtoxinA injected to the affected skin or mucosal region, has also been recently shown to be effective in reducing pain severity and attack frequency in a double-blind, saline injection placebo-controlled trial, although side effects included facial asymmetry lasting up to 7 weeks.

If medical therapy fails or is poorly tolerated, interventional treatments can be considered.

• Microvascular decompression (MVD) involves craniotomy and repositioning of vessels out of contact from the trigeminal nerve.
  Up to 80% of patients become pain-free following the procedure, with 73% maintaining pain freedom at 5 years; however, there are multiple risks of serious complications, as well as sensory loss in 7% of patients and hearing loss in up to 10% of patients.
• Gamma knife radiosurgery, in which a beam of radiation is focused at the trigeminal root, has been reported to result in pain freedom in 69% of patients after 1 year, with the number falling to 52% at 3 years.
  Complications include sensory loss or paresthesias in 6% to 13% of patients.

Finally, percutaneous procedures on the Gasserian ganglion, or rhizotomies, involve:

• Penetration of the foramen ovale and lesioning of the trigeminal ganglion and/or its roots via glycerol injection
• Radiofrequency thermocoagulation, or mechanical compression.

Studies about pain freedom

In a few studies using independent outcome measures, pain freedom was attained in 90% of patients immediately following rhizotomy, but dropped to 54% to 64% after 3 years.

Adverse effects are frequent, with sensory loss occurring in almost half of cases, dysesthesias in 6%, masticatory difficulties in up to 50%, and anesthesia dolorosa, or painful numbness that can develop 3 to 6 months after the procedure, in about 4%.

• Peripheral techniques involving interruption of the trigeminal nerve have only been reported in case series, and to date, there are no direct comparative studies of procedural therapies for TN.