Pain Can Teach the Doctor

I saw this CNN article on making the most of your life before you die, Opinion: When you’re dying, what will you regret? – CNN.com. I’m not dying, but I’ve recently developed a new challenge which can be associated with just getting older. It makes me more conscious of my mortality.

Trigeminal-neuralgiaSo let’s talk about neuropathic pain. I’m a consulting psychiatrist in an academic medical center and I see a lot of patients with many kinds of both acute and chronic pain. One example of neuropathic pain is Trigeminal Neuralgia (TN) and its second cousin, the atypical form of TN. It’s tough to diagnose because there’s a whole raft of facial pain syndromes that are frustratingly similar. If diagnostic criteria are met, all of them can come under the psychiatric rubric of somatoform disorders, now called Somatic Symptom Disorder in the Diagnostic and Statistical Manual (DSM)-5, http://www.dsm5.org/Documents/Somatic%20Symptom%20Disorder%20Fact%20Sheet.pdf. How do you feel about that? The number and complexity of them are staggering [1].

TN tends to show up in older people, maybe women slightly more than men although the literature is not firm on the gender distribution. It’s an agonizing pain on one side of the face (which has led to the name the “suicide disease”) that usually follows the distribution of one or more of the three divisions of the trigeminal nerve as it exits the base of the brain:

The most important first step is to make the diagnosis, which is often one of exclusion of many other causes of facial pain. Many people see a dentist first, as I did, assuming there’s a problem with the teeth. My dentist looked at me after a very thorough examination including x-rays and banging on my teeth on the right side, which drew no reaction at that time but which I could not tolerate now. His look reflected his doubt and bewilderment. He stumbled over his words as he tried to tell me he didn’t know what was wrong. So I spoke up and said, “You’re telling me you didn’t find an objective explanation for my pain?”He admitted that he had not. I told him I could live with that.  I assured him that I see people almost every day with medically unexplained physical symptoms. He didn’t recommend tooth extractions or root canals, which many TN sufferers endure in addition to the real problem, sometimes for years.

He did a good job.

An MRI is often recommended to rule out tumors. These are rare but can occur, as reported by Kim and colleagues [2]. The first line medical therapy for TN is an anticonvulsant, carbamazepine (Tegretol), which can be difficult for patients to tolerate at higher doses, because it has some side effects, including neutropenia (low white blood cell count). Other anticonvulsants and muscle relaxants either singly or in combination are often used. Combination drug regimens can be effective at controlling pain when resources are limited for the surgical treatment options [3]. The first choice of the surgical interventions is most often microvascular decompression, but there are alternatives:

I was able to find one systematic review of acupuncture for TN, and while the reviewer thought the efficacy of acupuncture was comparable to that of carbamazepine, the overall quality of the studies was pretty low [4]. I’m not sure if I could tolerate needles anywhere near my trigger points.

trigeminal-neuralgia-chiropracticoyThere’s no one-size-fits-all approach and the selection of medical therapy is usually first with surgical options considered only when the patient has intractable pain unresponsive to medications. It’s sort of analogous to psychiatrists waiting until someone is half dead from depression after many trials of antidepressants before applying electroconvulsive therapy (ECT). One study comparing clinical outcomes and costs of medical therapy versus surgery found mainly that the burden of cost for one form of drug therapy was more than that for microvascular decompression late in the treatment course, and that microvascular decompression could be marked by higher costs and more adverse effects, especially early in the course of treatment [5].

There is no question that TN can be marked by anxiety and depression, especially if the condition becomes chronic, which it often does [6]. Acknowledging this and preparing for it is critical. There is evidence that the central nervous system actually undergoes a physical change under a proposed “central sensitization model” when neuropathic pain becomes chronic [7]. This, in part, explains why someone can experience so much pain in spite of there being no outward “objective” evidence to account for the severity of pain.

I could find no credible evidence that stress or personality traits by themselves can cause TN (don’t believe everything Dr. Google tells you) in a cursory PubMed search. There’s plenty of evidence that they play a role in triggering pain, aggravating the suffering, and influencing the syndrome’s course in those who already have TN–and there’s hope that we can change as programs for biobehavioral pain management programs develop [8].

Beyond that, a psychological approach to assist patients in managing chronic neuropathic pain is essential. This can include cognitive behavioral therapy. Feinmann and colleagues’ stepwise approach includes:

1. Treat the cause of the pain.

2. Treat the pain, using, for example, antidepressants, anticonvulsants, analgesics, cognitive behavioral therapy (CBT), or hypnosis.

3. Address the patient’s suffering: Reduce the impact of chronic pain on his or her physical and psychological state and quality of life.

So do I have regrets? A few . So far I’m getting by on baby food, Malt-O-Meal, and Ensure, thinking this could be a good way to shed my spare tire; taking my medication and watching the clock; trying to talk a little less , which many will probably appreciate; and smiling despite the jolt that could make Jesus Christ sell his soul to the Devil for relief.

I think the most important lesson is that now I’m beginning to understand what some of my patients are enduring.

References:

1. Viana, M., C. Tassorelli, et al. (2013). “Diagnostic and therapeutic errors in trigeminal autonomic cephalalgias and hemicrania continua: a systematic review.” J Headache Pain 14(1): 14.

Trigeminal autonomic cephalalgias (TACs) and hemicrania continua (HC) are relatively rare but clinically rather well-defined primary headaches. Despite the existence of clear-cut diagnostic criteria (The International Classification of Headache Disorders, 2nd edition – ICHD-II) and several therapeutic guidelines, errors in workup and treatment of these conditions are frequent in clinical practice. We set out to review all available published data on mismanagement of TACs and HC patients in order to understand and avoid its causes. The search strategy identified 22 published studies. The most frequent errors described in the management of patients with TACs and HC are: referral to wrong type of specialist, diagnostic delay, misdiagnosis, and the use of treatments without overt indication. Migraine with and without aura, trigeminal neuralgia, sinus infection, dental pain and temporomandibular dysfunction are the disorders most frequently overdiagnosed. Even when the clinical picture is clear-cut, TACs and HC are frequently not recognized and/or mistaken for other disorders, not only by general physicians, dentists and ENT surgeons, but also by neurologists and headache specialists. This seems to be due to limited knowledge of the specific characteristics and variants of these disorders, and it results in the unnecessary prescription of ineffective and sometimes invasive treatments which may have negative consequences for patients. Greater knowledge of and education about these disorders, among both primary care physicians and headache specialists, might contribute to improving the quality of life of TACs and HC patients.

2. Kim, M. S., Y. J. Ryu, et al. (2013). “Secondary trigeminal neuralgia caused by pharyngeal squamous cell carcinoma – a case report.” Korean J Pain 26(2): 177-180.

Trigeminal neuralgia (TN) is characterized by recurrent paroxysms of unilateral facial pain that typically is severe, lancinating, and activated with cutaneous stimulation. There are two types of TN, classical TN and atypical TN. The pain nature of classical TN are the same as those described above, whereas atypical TN is characterized by constant, burning pain. We describe the case of a 49-year-old male presenting with right-sided facial pain. The patient was diagnosed with temporomandibular joint disorder at a dental clinic and was on medical treatment, but his symptoms worsened gradually. He was referred to our pain clinic for further evaluation. Radiologic evaluation, including MRI, showed a parapharyngeal tumor. For the relief of TN, a right mandibular nerve (V3) root block was performed at our pain clinic, and then he was scheduled for radiation and chemotherapy.

3. Ariyawardana, A., R. Pallegama, et al. (2012). “Use of single- and multi-drug regimens in the management of classic (idiopathic) trigeminal neuralgia: an 11-year experience at a single Sri Lankan institution.” Journal of Investigative and Clinical Dentistry 3(2): 98-102.

Aim:  The aim of this retrospective study was to evaluate the outcome of medical treatment of classic trigeminal neuralgia and to assess the factors affecting the choice of drug regimen (single or multiple), and the duration of treatment for pain control. Methods:  A total of 260 consecutive patients were included in the study. Sixty-one patients with less than 6 months’ follow up were excluded. All patients were treated with carbamazepine alone or in combination with other drugs. The dosage was adjusted according to the level of pain control and side-effects. Results:  Treatment was terminated in 99 patients (49.7%) after a mean follow-up period of 36.46 months (standard deviation: ±26.5). Of these, 39.4% were on a single drug. Carbamazepine was the drug used in 36 patients. The rest (61%) needed various combinations of drugs. One-hundred patients (50.3%) continued with medical treatment during the follow-up period. Of these, 67.4% were on multi-drug therapy. Conclusion:  The present study showed that the administration of multidrug regimens is a useful alternative in controlling trigeminal neuralgia in patients who are unable to tolerate higher doses of carbamazepine. Age, sex, ethnicity, and the side of affliction did not have a significant influence on the choice of drug regimen and the duration of treatment for pain control.

4. Liu, H., H. Li, et al. (2010). “A systematic review on acupuncture for trigeminal neuralgia.” Altern Ther Health Med 16(6): 30-35.

BACKGROUND: Trigeminal neuralgia (TN) is a commonly seen pain condition with limited treatments available, and acupuncture is widely used for pain conditions, including TN. OBJECTIVES: To review the efficacy of acupuncture treatment for TN. METHODS: English and Chinese databases were searched extensively to identify randomized controlled studies of acupuncture treatment for TN. Selected studies were assessed for methodological quality. Odds ratios (OR) between treatment and control groups were used to assess efficacy. RESULTS: Twelve studies met the inclusion criteria with 506 people in the acupuncture arm and 414 people in the control arm, in which carbamazepine (CBZ) was used as the control treatment. They were all low-quality studies, hence precluding meta-analysis. Only four trials reported that acupuncture was superior to CBZ, and the remaining eight studies showed no difference between the treatment and control groups. Adverse effects of acupuncture, which were reported in three studies, were mild. CONCLUSION: The evidence reviewed previously suggests that acupuncture is of similar efficacy as CBZ but with fewer adverse effects in treatment of TN. However, the evidence is weak because of low methodological quality of the reviewed studies. Further studies with improved methodologies are recommended to support the use of acupuncture for TN.

5. Lemos, L., C. Alegria, et al. (2011). “Pharmacological versus microvascular decompression approaches for the treatment of trigeminal neuralgia: clinical outcomes and direct costs.” J Pain Res 4: 233-244.

In idiopathic trigeminal neuralgia (TN) the neuroimaging evaluation is usually normal, but in some cases a vascular compression of trigeminal nerve root is present. Although the latter condition may be referred to surgery, drug therapy is usually the first approach to control pain. This study compared the clinical outcome and direct costs of (1) a traditional treatment (carbamazepine [CBZ] in monotherapy [CBZ protocol]), (2) the association of gabapentin (GBP) and analgesic block of trigger-points with ropivacaine (ROP) (GBP+ROP protocol), and (3) a common TN surgery, microvascular decompression of the trigeminal nerve (MVD protocol). Sixty-two TN patients were randomly treated during 4 weeks (CBZ [n = 23] and GBP+ROP [n = 17] protocols) from cases of idiopathic TN, or selected for MVD surgery (n = 22) due to intractable pain. Direct medical cost estimates were determined by the price of drugs in 2008 and the hospital costs. Pain was evaluated using the Numerical Rating Scale (NRS) and number of pain crises; the Hospital Anxiety and Depression Scale, Sickness Impact Profile, and satisfaction with treatment and hospital team were evaluated. Assessments were performed at day 0 and 6 months after the beginning of treatment. All protocols showed a clinical improvement of pain control at month 6. The GBP+ROP protocol was the least expensive treatment, whereas surgery was the most expensive. With time, however, GBP+ROP tended to be the most and MVD the least expensive. No sequelae resulted in any patient after drug therapies, while after MDV surgery several patients showed important side effects. Data reinforce that, (1) TN patients should be carefully evaluated before choosing therapy for pain control, (2) different pharmacological approaches are available to initiate pain control at low costs, and (3) criteria for surgical interventions should be clearly defined due to important side effects, with the initial higher costs being strongly reduced with time.

6. Macianskyte, D., G. Januzis, et al. (2011). “Associations between chronic pain and depressive symptoms in patients with trigeminal neuralgia.” Medicina (Kaunas) 47(7): 386-392.

Trigeminal neuralgia (TN) is a rare neuropathic disorder with an excruciating facial pain. The unpredictable pain attacks may result in anxiety and depression. The aim of this study was to determine and to evaluate the level of chronic facial pain and its association with the appearance of anxiety and depression. MATERIALS AND METHODS: A total of 30 patients with TN and chronic facial pain (group A, 25 women and 5 men; mean age, 64.2+/-3.2 years) and 30 with atypical facial pain (group B, 26 women and 4 men; mean age, 64.8+/-1.9 years) were examined. A standardized diagnostic protocol was applied to all of them, which consisted of the following: 1) demographic data and estimation of overall pain on a visual analog scale; and 2) evaluation of emotional status using the Sheehan Disability Scale, Covi’s Anxiety Scale, and Beck Depression Inventory. RESULTS: The intensity of facial pain was much higher in the group A than the group B (89.7+/-2.5 versus 44.0+/-2.9, P<0.0001). Besides, the group A reported increased scores on the disability and anxiety symptom scales (17.4+/-1.3 and 9.7+/-0.3 vs. 6.4+/-0.7 and 3.6+/-0.1, respectively, P<0.0001). Severe (46.7%) or moderate (30%) levels of depression were documented in the majority of patients in the group A, while the group B did not show depressive symptoms (P<0.0001). CONCLUSIONS: Patients with TN and chronic facial pain had a significantly higher level of pain perception, and they presented the higher level for anxiety and depression than those with atypical facial pain. A multidisciplinary approach is needed for the additional assessment of emotional status of patients in order to improve the efficacy of treatment and patients’ quality of life.

7. Feinmann, C. and T. Newton-John (2004). “Psychiatric and psychological management considerations associated with nerve damage and neuropathic trigeminal pain.” J Orofac Pain 18(4): 360-365.

This article reviews current models of neuropathic pain and relates recent research in the neurobiology of pain to improved understanding of psychiatric and psychological aspects and treatment of chronic aspects of pain. Some of the anomalies associated with beliefs about chronic pain are also outlined. In particular, the notion that pain is either verifiable or due to psychiatric disturbance is laid to rest; the onus is on the clinician to understand and treat the patient with sensitivity, rather than on the patient to provide proof of pain.

8. Carlson, C. R. (2007). “Psychological Factors Associated with Orofacial Pains.” Dental Clinics of North America 51(1): 145-160.

This article develops the case for why trigeminal pain is a unique and challenging problem for clinicians and patients alike, and provides the reader with insights for effective trigeminal pain management based on an understanding of the interplay between psychologic and physiologic systems. There is no greater sensory experience for the brain to manage than unremitting pain in trigeminally mediated areas. Such pain overwhelms conscious experience and focuses the suffering individual like few other sensory events. Trigeminal pain often motivates a search for relief that can drain financial and emotional resources. Therefore, it is not uncommon for individuals to spend hundreds, if not thousands, of dollars in the quest for quieting trigeminal pain. In some instances, the search is rewarded by a treatment that immediately addresses an identifiable source of pain (eg, appropriate endodontic treatment for an infected tooth). In other cases, however, it can stimulate never-ending pilgrimages from one health provider to another in the hopes of finding some relief for unrelenting trigeminal pain. Ongoing trigeminal pain demands attention and can prevent an individual from living any semblance of a normal life.

Web Resources:

HIE Multimedia: Trigeminal neuralgia

Trigeminal neuralgia – Wikipedia, the free encyclopedia

TNA The Facial Pain Association | An advocate for patients living with neuropathic facial pain, including trigeminal neuralgia, by providing information, encouraging research and offering support.

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