Severe pain in the tongue leads to the diagnosis of trigeminal neuralgia

Dr. Keith Roach

DEAR DR. ROACH: I’m a 76 year old male. A few months ago I suddenly had the worst pain of my life, centered on the right side of my tongue, of all places. It felt like a live electric wire was touching my tongue. It was excruciating. I had been to a dentist the previous week, but only to have an implant crown liner replaced. No injections or anesthesia were necessary. Could I have opened my mouth a little too much and hurt a nerve?
After three ER visits, I was placed on gabapentin and viscous lidocaine. I was finally able to see an ENT doctor, who immediately diagnosed my condition as trigeminal neuralgia. Gradually, the condition disappeared.
But, I wonder, what causes trigeminal neuralgia in the first place, and will it come back? Does the severity of spastic pain cause nerve damage? Is it by chance viral? —WW
ANSWER: “Trigeminal” means “born in threes” (like triplets) and refers to the fact that the trigeminal nerve, also called the fifth cranial nerve, has three roughly equal divisions: V1 (the ophthalmic nerve), V2 (the maxillary nerve). nerve) and V3 (the mandibular nerve). Trigeminal neuralgia (NT) is a nerve pain syndrome arising from one or more branches of the trigeminal nerve.
The electric shock sensation you feel is common in TN and in nerve disorders in general (many people worry about circulation with this symptom, but it’s almost always due to nerve pain). In TN the pain comes and goes often, sometimes a few times, sometimes more than 50 times a day. However, some people have continuous pain. Pain in the V2 and V3 distributions are often misdiagnosed as dental issues, and I’ve seen people come in with dental extractions that failed to relieve the symptom. It’s also possible that the pain is triggered by dental procedures (it doesn’t mean the dentist did anything wrong, only that they triggered an underlying problem). Many of my patients have been misdiagnosed for months or even years.
The underlying cause of TN, when it can be found, is most often nerve compression, usually in the brainstem where the nerve root begins. A blood vessel compressing the nerve root is thought to account for 80-90% of cases. Viruses, such as shingles, can cause pain similar to an electric shock, so your guess was correct, but viruses are not thought to be part of trigeminal neuralgia.
Periods without pain are common in TN, but the pain most often returns. The pain-free interval can be weeks, months, or years.
Gabapentin, an anti-epileptic drug often used for nerve pain, is a treatment, as is another anti-epileptic drug, carbamazepine. Pain management specialists can be very helpful. Surgery is sometimes used in patients with TN who cannot be adequately relieved by painkillers, and although it is often initially successful, pain may return years after surgery. Surgery can also lead to complications.
I recommend a trigeminal neuralgia support group, such as facepain.org and livingwithfacialpain.org.

Dr Roach regrets that he cannot respond to individual letters, but will incorporate them into the column whenever possible. Readers can send questions to [email protected] or mail to 628 Virginia Dr., Orlando, FL 32803.
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