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GUIDE TO NERVE PAIN OR NEURALGIA

WHAT IS NERVE PAIN OR NEURALGIA?

Nerve pain or neuralgia is the pain in one or more nerves due to a lack of pain receptor stimulation cells or nociceptor cells. It may be produced due to a change in the neurological function or structure of the pain receptors resulting to nociceptive pain. Neuralgia can be categorized into two: central neuralgia and peripheral neuralgia. There are four possible mechanisms that are being linked to the pain being felt: mechanical sensitivity of the nerves and creation of an ectopic signal, damage to the central processor causing malfunction, malfunctions to the ion gates and cross signals between the small and large fibres.

GENERAL SYMPTOMS OF NERVE PAIN OR NEURALGIA:

Nerve pain or neuralgia manifests itself in multiple conditions. General symptoms include:

·         Cheek pain

·         Aching teeth

·         Ear aches

·         Fullness feeling in the sinuses

·         Jaw pain

·         Pain around the eyes

·         Temples and forehead pain

·         Intense itching

·         Stabbing or shooting pain

PROGNOSIS OF NERVE PAIN OR NEURALGIA:

Most neuralgia is not life-threatening. However, pain can be severe. Make sure to seek medical device when pain arise. The pains usually come and go. The pain usually gets frequent as the patient gets older.

WHEN TO CONTACT YOUR DOCTOR:

·         You have severe pain

·         You have shingles

·         You have symptoms of neuralgia; if over-the-counter drugs do not relieve the pain

DIAGNOSIS OF NERVE PAIN OR NEURALGIA:

Diagnosis of neuralgia is difficult and misdiagnosis is common. This involves locating the damage nerve by stimulating specific nerve pathways or identification of the missing sensory function.

Nerve conduction study- the most common test for neuralgia such as microneurography wherein the peripheral nerve is stimulated.

Postherpetic Neuralgia- is easy to diagnose for it only occurs as a result of shingles. The doctor can diagnose it by identifying the symptoms and by length of time that you have had shingles.

Assessing the pain of neuralgia to identify the underlying mechanism includes:

·         History of pain

·         Description of pain

·         Clinical examination- testing responses to stimuli such as temperature, vibration and touch

·         Experimental examination

·         Use of pain scale such as McGill Pain Questionnaire

There are no specific tests to diagnose neuralgia. These exams are used in identifying the cause of the pain. These include:

·         MRI

·         Punch Skin Biopsy

·         Quantitative sensory testing

·         Laser evoked potentials

·         Blood tests to check kidney function and blood sugar

·         Spinal tap (lumbar puncture)

·         Nerve conduction study with electromyography

Dental examination to rule out dental disorders that causes facial pain

SPECIFIC CONDITIONS:

1.    Trigeminal Neuralgia (Atypical)

The trigeminal nerve or the 5^th cranial nerve is one of the primary nerves of the face. There are one on each side of the face and is called trigeminal for it splits into three branches. The first branch goes to the forehead, scalp and around the eyes. The second branch goes around the cheeks. The third branch goes around the jaw. The trigeminal nerves give sensation and pain to the face, mouth and teeth. It is also controls the muscles of chewing and the production of saliva and tears.

Trigeminal Neuralgia is the common form of neuralgia and is the one which is most misdiagnosed. The symptoms manifested by ATN are usually mistaken as symptoms of other conditions like hypochondriasis, musculoskeletal issues, migraines and tempomandibular joint disorders. The pain can be varying from its intensity; can be of aching, crushing or burning sensation. Patients can experience pain the three trigeminal nerve branches.

Trigeminal Neuralgia usually affects older people and usually starts at the age of 60. Women are more affected than men.

Possible causes of Trigeminal Neuralgia may include:

·         Physical trauma

·         Vascular compression of the Trigeminal nerve

·         History of viral infections

·         Sinus or teeth infections

·         Multiple Sclerosis

·         Abnormality of the skull’s base

Signs and symptoms of trigeminal neuralgia may include the following:

·         Cheek pain

·         Aching teeth

·         Ear aches

·         Fullness feeling in the sinuses

·         Jaw pain

·         Pain around the eyes

·         Temples and forehead pain

The pain tends to worsen during:

·         Chewing

·         Talking

·         Facial expression

·         Certain sensation like cool breeze

·         Certain activities like brushing teeth, washing the face and shaving

2.    Glossopharyngeal Neuralgia - This is due to a malfunction to the 9^th cranial nerve (glossopharyngeal nerve) which is responsible to the movement of the throat muscles. It carries information from the throat, tonsils and tongue to the brain. This is a rare disorder that affects men than women and usually begins after the age of 40. Most often, the cause is unknown but in rare cases, it can be caused by a tumor in the neck or brain. Sometimes, an abnormally positioned artery that compresses the glossopharyngeal nerve.

3.    Occipital Neuralgia- also known as Arnold’s Neuralgia or C2 Neuralgia. This condition is characterized by chronic pain behind the eyes, back of the head and upper neck.

4.    Postherpetic Neuralgia - Postherpetic Neuralgia is a result of shingles. It is a constant and severe nerve pain. Shingles is a viral infection caused by Varicella Zoster virus. This affects the nerves of the chest and abdomen causing pain to the nerves ad leaves rashes on one side of the body. Shingles usually last for 2 to 4 weeks. If the pain lasts longer than this after the rashes are healed then it is called postherpetic neuralgia. Adults are more common to have this than children. Research said that 20% of people who have shingles may develop postherpetic neuralgia.

Signs and symptoms of postherpetic neuralgia include:

·         Intense itching

·         Stabbing or shooting pain

·         Constant throbbing, burning or aching pain on the location where you had shingles

·         The pain is worsen by cold or heat

SECONDARY SIGNS AND SYMPTOMS:

·         Malnutrition

·         Sleep Deprivation

TREATMENTS:

For Postherpetic Neuralgia:

·         Painkillers- it will depend on the severity of the symptoms but initially Paracetamol is given. Codeine can also be given alongside with Paracetamol.

·         Antidepressants- Tricyclic antidepressants are given to ease the pain. They react on the chemicals on the brain making them less sensitive to pain. These may include Amitriptyline, imipramine or nortriptyline. These drugs may cause side effects such as drowsiness and dry mouth.

·         Anticonvulsants- these are given to patients who are not allowed to take tricyclic antidepressants. Anticonvulsants like Gabapentin can calm down the nerve impulses. Drowsiness, dizziness and muscle weakness are common side effects of Gabapentin.

·         Capsaicin cream- if the painkillers are not enough and antidepressants and anticonvulsants are not suitable for the patient, capsaicin cream is prescribed. It works by blocking the nerves the passages that sends the pain message. This cream may cause a burning sensation so avoid taking a hot bath before or after applying it.

·         Lidocaine patches- contain local anesthetics that act as painkiller on the area where it is applied.

·         Self-help- wear comfortable clothing. Clothes that are too tight, rough or made of synthetic may irritate the skin. Wear loose and cotton clothes to avoid irritation. Cover the affected areas so that they will not be irritated. Use cold packs to nub the senses, unless pain is worsened by cold.

For Trigeminal Neuralgia:

1.    Anticonvulsants- these are drugs use to prevent seizures. These drugs are used to patients with Trigeminal Neuralgia for it calm down the never impulses. Gabapentin and Carbamazepine are commonly used. Drowsiness, dizziness, nauseas and vomiting are the common side effects of anticonvulsants. A blood test is required in people with Chinese and Thai ethnicity before taking Carbamazepine for this drug can cause rashes to these people with certain genetic type.

2.    Surgery-the aim of surgery is to stop the blood vessels to put pressure on the trigeminal nerve or damaging the nerves. There are several surgeries that are performed in treating trigeminal neuralgia. The physician must fully explain this to the patient.

·         Microvascular decompression- the most effective operation for Trigeminal neuralgia. This operation releases the pressure of the blood vessels that are compressing the trigeminal nerve. The blood vessels are either relocated or remove to separate it from the trigeminal nerve. The operation can sometimes cause complications double vision, facial weakness and damage hearing to one ear.

·         Stereotactic radiosurgery- uses concentrated beam of radiation to reduce the effectiveness of the trigeminal nerve. It is a type of “gamma ray knife surgery” for it does not require an incision to the skin or any anesthetic.

·         Nerve block- anesthetics are injected to the face for several weeks or months

·         Alcohol injections- given into the end of the nerves to numb your pain

·         Glycerol injections- injected to the area where the three branches of the trigeminal nerve join

·         Cryotherapy- the trigeminal nerve is frozen using chemicals

·         Neurectomy- the end of the nerves are cut

·         Balloon compression- a tiny balloon is inflated to the trigeminal nerve to relieve the pressure

·         Electric current- electric current is used to numb the trigeminal nerve

·         Peripheral radiofrequency thermocoagulation- radiation is used to damage the nerve endings

·         Rhizotomy- selected nerve fibers are destroyed to block the pain

3.    Self-help- if the pain is worsened by wind or by a draught in a room, avoid sitting near an open window or near a source of air-conditioning. Wear scarf around your face. Avoid hot or cold if it triggers the pain.

4.    Complementary Techniques- often used alongside with drugs. These therapies include:

·         Biofeedback

·         Vitamin therapy

·         Nutritional therapy

·         Hot-cold compress

·         Acupuncture

·         Chiropractic

·         Electrical stimulation of the nerves

COMPLICATIONS:

·         Complications of surgery

·         Side effects of medications used to control pain

·         Disability caused by pain

REFERRENCES:

·         http://en.wikipedia.org/wiki/Neuralgia

·         http://www.cks.nhs.uk/patient_information_leaflet/neuralgia

·         http://www.nlm.nih.gov/medlineplus/ency/article/001407.htm

·         http://www.patient.co.uk/health/Trigeminal-Neuralgia.htm

·         http://www.nhs.uk/conditions/postherpetic-neuralgia/Pages/Introduction.aspx

·         http://arthritis.about.com/od/nervepain/Nerve_Pain_Causes_Symptoms_Diagnosis_Treatment_Pain_Relief.htm