Relief for Trigeminal Neuralgia Pain

For people with trigeminal neuralgia, a passing breeze can be a threat. Even the lightest stimulation of the face can spark episodes of excruciating pain and muscle spasms in the face, jaw, and forehead.

Patients describe it in similar ways: like being stabbed, electrocuted, or hit by light­ning. The pain comes and goes with no warning and occurs for seconds or minutes, hundreds of times a day. 

“You can’t imagine how many people are in their beds right now in agony, losing days to this pain, and living like this for years,” says neurosurgeon Raymond Sekula, MD, an expert in treating trigeminal neuralgia who joined Columbia from the University of Pittsburgh in February 2022. 

Not surprisingly, studies show that patients experience depression, social isolation, and sometimes suicidal thoughts, making it among the most debilitating medical conditions. 

Dr. Sekula is one of the most experienced neurosurgeons in the United States who perform microvascular decompression, or MVD, a minimally invasive brain surgery to reduce or stop craniofacial pain. He has performed thousands of the procedures over the past 15 years.

Most cases of trigeminal neuralgia are caused by compression of the trigeminal nerve by an adjacent blood vessel near the brainstem. MVD relieves pressure on the trigeminal nerve by relocating the blood vessel away from the nerve entirely or by placing padding between the blood vessel and the nerve to separate the two. It’s a delicate operation that requires the neurosurgeon to drill a hole in the skull just behind the ear and work through a 3-inch-deep hole about the width of a pencil to pry apart the nerve and vessel, which are usually tightly tethered together.

More people could benefit from microvascular decompression, but Dr. Sekula says that the extraordinary pain of trigeminal neuralgia is often dismissed as stress or not worth the risks of brain surgery. Medications are usually tried first, but in Dr. Sekula’s experience, the pain returns. Patients often experience remissions of the pain, which can last for months. Over time, however, the remissions grow shorter, and the severity of the pain attacks worsens.

Most patients are desperate to try anything to get relief, regardless of risk, Dr. Sekula says. But after years of analyzing data from his patients, he knows that surgery does not work for everyone. His rating system, published in 2019 in the journal Neurosurgery, scores candidates between 1 and 5, based on types of symptoms, response to medication, and degree of vascular compression. About 90% of patients who score a 5 experience long-term pain relief from MVD, but the odds of long-term relief decline with lower scores. 

For patients who are not candidates for decompression surgery and are unable to get relief from other treatments, Dr. Sekula’s NIH-funded lab is looking for solutions. By analyzing differences in trigeminal nerve and sciatic nerve pain, the lab has found that the trigeminal nerve responds differently to injury than the sciatic nerve, and researchers are using that information to design better drugs. 

“These people will live in agony unless there’s some way we can intervene,” says Dr. Sekula.

— Sara Pepitone


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