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Q
Pain in the Face?

What is the best treatment for trigeminal neuralgia? I am currently on 900 mg of Neurontin a day. I've heard of a couple procedures that go into the cheek and kill the nerves.

A
Answer (Published 6/24/2005)

Trigeminal neuralgia, sometimes called tic douloureux, is an extremely painful condition that causes sudden, intense facial pain most often described as "stabbing" or "lightning-like."  It is due to irritation of the trigeminal nerve, a cranial nerve that normally senses touch, pain, temperature, and pressure on the face. Usually, the irritation stems from pressure on the nerve from an abnormal blood vessel, but the problem can also be related to a tumor or, less commonly, to a rare type of stroke. As many as eight percent of multiple sclerosis patients develop trigeminal neuralgia due to the wearing away of part of the protective covering (myelin sheath) that insulates nerve fibers.

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The drug you are taking, Neurontin, is an anti-seizure medication usually prescribed to treat epilepsy. It is one of a number of drugs that can reduce the sensitivity of the trigeminal nerve. If the Neurontin is not working, I suggest that you request a trial of intranasal Nubain, a non-addictive narcotic painkiller with a low abuse potential. Nubain (nalbuphine hydrochloride) usually comes in injectable form but your physician can ask your pharmacist to make a nasal spray for you. Nubain is a safe drug that works well for some people with your condition. You also could try taking a calcium/magnesium supplement, which can help calm overactive nerves. In addition, I recommend that you try acupuncture and hypnosis, both of which can be helpful. Finally, you might experiment with an extract of lion's mane mushroom (Hericium erinaceus), which provides nerve growth factors.

Several surgical procedures are available for treating trigeminal neuralgia if all else fails, but I consider them drastic options to be considered only as last resorts. One procedure inactivates a section of the trigeminal nerve. It works initially in 99 percent of all cases, but up to 50 percent of patients eventually experience recurrences. Another type of surgery that provides long term relief to between 70 and 80 percent of patients involves repositioning the blood vessel that is pressing on the nerve, if that is the problem. However, this operation requires opening the skull and usually is recommended only for patients under the age of 65.

Andrew Weil, M.D.

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