Neuralgia

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Neuralgia is a painful disorder of the nerves. Under the general heading of neuralgia are trigeminal neuralgia (TN), atypical facial pain, and postherpetic neuralgia (caused by shingles or herpes).

The affected nerves are responsible for sensing touch, temperature sensation and pressure sensation in the facial area from the jaw to the forehead. The disorder generally causes short episodes of excruciating pain, usually for less than two minutes and on only one side of the face. The pain can be described in a variety of ways such as “stabbing,” “sharp,” “like lightning,” “burning,” and even “itchy”. In the atypical form of TN, the pain can also present as severe or merely aching and last for extended periods. The pain associated with TN is recognized as one of the most excruciating pains that can be experienced.

Simple stimuli such as eating, talking, washing the face, or any light touch or sensation can trigger an attack (even the sensation of a gentle breeze). The attacks can occur in clusters or as an isolated attack. Some patients will have a muscle spasm which led to the original term for TN of “tic douloureux” (“tic”, meaning ‘spasm‘, and “douloureux”, meaning ‘painful’, in French).

Neuralgia is a form of chronic pain and can be extremely difficult to diagnose. Patients usually show no physical abnormalities, and with the attacks generally lasting a very short time, it can be difficult to reach a doctor before the attack is over. Postherpetic neuralgia is the easiest to diagnose because it follows an obvious cause (shingles).

Neuralgia is rare, especially in those under 30. Women are more likely to be affected than men, and those over 50 are at the greatest risk. In some cases, multiple sclerosis is related to nerve damage, causing the pain, so doctors will likely ask about family history to help diagnose. Nothing unusual can be seen in brain scans, so diagnosis is usually based on the description of the symptoms.

Medication for seizures has shown promise in managing neuralgia, and some people have found relief with surgery, though not always permanent relief.

Neuralgia is more common in elderly people, but it may occur at any age.

Blood tests to check blood sugar, kidney function, and other possible causes of neuralgia

• Nerve conduction study with electromyography
• Spinal tap (lumbar puncture)

Surgery to remove pressure on the nerve from nearby bones, ligaments, blood vessels, or tumors may be needed. See:

• Carpal tunnel syndrome
• Trigeminal neuralgia

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In many cases, the cause is unknown. Postherpetic neuralgia and trigeminal neuralgia are the two most common forms of neuralgia. A related but less common neuralgia affects the glossopharyngeal nerve, which provides feeling to the throat.

Not all of those diagnosed with shingles go on to experience postherpetic neuralgia, which can be more painful than shingles. The pain and sensitivity can last for months or even years. The pain is usually in the form of an intolerable sensitivity to any touch but especially light touch. Postherpetic neuralgia is not restricted to the face; it can occur anywhere on the body but usually occurs at the location of the shingles rash. Depression is not uncommon due to the pain and social isolation during the illness. Treatment for postherpetic neuralgia is the same as for other forms.

The symptoms of atypical neuralgia (ATN) tend to be vague and misleading. This may be the most misdiagnosed form of neuralgia. The symptoms can be mistaken for migraines, dental problems such as TMJ, musculoskeletal issues, and hypochondriasis. This form of neuralgia is extremely rare, thus also contributing to the misdiagnosis. ATN can have a wide range of symptoms and the pain can fluctuate in intensity from mild aching to a crushing or burning sensation, and also to the extreme pain experienced with the more common trigeminal neuralgia.

The pain from ATN is usually less than that of trigeminal neuralgia, but is nearly continuous and periods of remission are rare. This form can also cause pain in the back of the scalp and neck.

Many attempts have been made to link ATN with psychological issues, though modern studies have shown no link. Theories have suggested that infections of the teeth or sinuses, vascular compression, physical trauma, or past viral infections could be a cause. Evidence thus far seems to be anecdotal. Another interesting aspect is that this form affects men and women equally, unlike the trigeminal neuralgia, which is much more common in women than men.

ATN is also known as Atypical Facial Pain (ATP) or Persistent Idiopathic Facial Pain (PIFP).

• Chemical irritation
• Chronic renal insufficiency
• Diabetes
• Drugs
  • Ixabepilone
  • Pergolide
• Infections, such as herpes zoster ( shingles), HIV, Lyme disease, and syphilis
• Medications such as Enfuvirtide, cisplatin, paclitaxel, or vincristine, leflunomide, oxcarbazepine, pentamidine Isethionate
• Porphyria
• Pressure on nerves by nearby bones, ligaments, blood vessels, or tumors
• Trauma (including surgery)

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Neuralgia is more common in elderly people, but it may occur at any age.

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Neuralgia usually goes undiagnosed or misdiagnosed for extended periods, leading to a great deal of pain and frustration on the part of the patient. This disease has earned the nickname “the suicide disease,” due to the unfortunate and drastic steps some have taken when they have been unable to find relief. Patients exhibiting symptoms need to be persistent, and willing to try different doctors to find the help they need.

Sleep deprivation and malnutrition have also been reported as byproducts of the pain. It is possible that there are other triggers or aggravating factors that patients need to learn to recognize to help manage their health. Bright lights, sounds, stress, and poor diet are examples of additional stimuli that can contribute to the condition. The pain can cause nausea, so beyond the obvious need to treat the pain, it is important to be sure to try to get adequate rest and nutrition.

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• Complications of surgery
• Disability caused by pain
• Side effects of medications used to control pain
• Unnecessary dental procedures before neuralgia is diagnosed

Most neuralgias are not life-threatening and are not signs of other life-threatening disorders. However, pain can be severe. For severe pain that does not improve, see a pain specialist so that you can explore all treatment options. Most neuralgias will respond to treatment. Attacks of pain usually come and go. However, attacks may become more frequent in some patients as they get older.

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