Ask Us Anything About… Face Pain

Description – The video begins inside Penn State Health Milton S. Hershey Medical Center. Two people are standing next to each other inside the waiting room in the South Annex of the Hershey Medical Center. From left to right is, Dr. Jim Mcinerney and Scott Gilbert.

Scott Gilbert – Good afternoon from Penn State Health, this is Ask Us Anything About Face Pain. I’m Scott Gilbert. Most of the time, when we experience some sort of face pain, we associate it with a headache or a dental issue. And some cases, such pain that becomes more frequent or severe over time could signal something more serious, such as the condition trigeminal neuralgia. We are going to learn more about that today from Dr. Jim McInerny, he’s a neurosurgeon here at Penn State Health, Milton S. Hershey Medical Center, Dr. McInerny thanks for your time, and welcome back to Ask Us Anything and we had you on before talking about gamma knife, and we will be talking a little bit about that on this program as well. Let’s start by talking about that ache in the face, you know, toothaches and headaches are very common. What are the signs to you as a physician that someone might be dealing with something a little more than that?

Dr. Jim Mcinerney – Sure. Well, I mean, one of the things that I always say is I don’t worry so much about things that come and go. I worry about things that come and stay. And that’s certainly one of the things that is pretty common with trigeminal neuralgia. It’s a very severe pain, so that is one of the differences. People will rate this as the worst pain that they’ve ever had. People who have had other severe pains, like childbirth, heart attacks, kidney stones, those can all be really severe pains, and yet they will often say this is worse than that.

Scott Gilbert – Do they start like that, or do they start as a minor pain and get worse?

Dr. Jim Mcinerney – A lot of times they start smaller, but one of the hallmarks of trigeminal neuralgia is that it comes and go, and it tends to sort of crescendo over time, so it gets more and more severe, and the attacks become more and more frequent. And people will usually describe it as like an electric shock type pain or a stabbing pain. And really, really severe.

Scott Gilbert – So what role does, do those things, the patient describes the pain, how they describe their pain, how does that factor into the diagnosis? How do you kind of break this down?

Dr. Jim Mcinerney – Sure, well one of the tough things about all pain syndromes is that they usually are what we call a clinical diagnosis. Meaning, there is no real gold standard test that says you know this is the problem that you have. And so when we talk about a clinical diagnosis, what we have to go on is history, what the patient tells us about their pain, physical exam, which unfortunately for trigeminal neuralgia is usually pretty normal, and then their response to treatment. Did they respond to the kind of treatments that trigeminal neuralgia usually responds to. And that’s pretty much it. And so to a certain extent, a, you know, a trial and error type of, you know, process that allows us to focus in on what really seems to be the major problem.

Scott Gilbert – You are watching Ask Us Anything About Face Pain, from Penn State Health, I am Scott Gilbert, alongside Dr. Jim McInerny. He is a neurosurgeon here at the Milton S. Hershey Medical Center, and Dr. McInerny welcomes your question and your comments. If you’re having face pain, or perhaps you know someone who is, and you have some questions as to whether it may show signs of trigeminal neuralgia, feel free to add your questions in the comment field below this Facebook post. So we are talking a bit about diagnosis here, and it seems like so much of ruling in trigeminal neuralgia would amount to ruling out other things, right?

Dr. Jim Mcinerney – Correct. And we do sometimes get imaging studies. I mean, occasionally somebody could have a tumor or something else going on that we might see on an MRI. We will sometimes, you know, welcome the opinions of other physicians, and even dentists, I mean, some dental things could look like trigeminal neuralgia. But very typically when somebody does have trigeminal neuralgia, the dental procedures aren’t going to fix the problems. I mean, that is one of the giveaways sometimes for us. Someone will come in having been to the dentist, and even had teeth pulled and things like that, but their pain is still persisting.

Scott Gilbert – So what is going on inside the body, what is it about the trigeminal nerve, that is happening with it, that is causing this intense pain?

Dr. Jim Mcinerney – Right, that’s a really great question. And we don’t know this 100% because, you know, pain is not an easy thing to experiment on, we can’t experiment on humans, and animals often can’t tell us when they have pain, so we are limited in what we can actually see. But we believe that this is usually caused by a blood vessel on the inside of the head, actually pushing against the nerve, and that pulsation, every time, it’s usually an artery, every time the heart beats, the artery pulses, and it’s right up against the nerve, and keeps on hitting it over, and over, and over again. And what we think happens over time is that causes the insulating fibers between the actual signaling fibers and the nerve to break down, and now all these fibers start to set each other off. Which is why people, we think, have triggers. Right? So it’s a common thing with trigeminal neuralgia, people can’t eat, or brush their teeth, or wash their face, because they’ll do something innocuous, and all of a sudden it will set of this attack of pain. And that is why we think that happens, because now at a normal sensation, it’s now setting off a pain fiber that it shouldn’t be setting off, and these abnormal signals are now coming back to the brain as pain, and that is what we believe is happening. So even though the pain is experienced out here in the face, the problem is actually back inside the head, where the nerve goes into the brain.

Scott Gilbert – So obviously some life limiting traits here in this pain. What about life threatening?

Dr. Jim Mcinerney – Well, you know, pain is not life threatening. You know, it can be very, very severe, and you know, sometimes well you say it’s not life-threatening it sounds like it’s not serious. This is serious, because I mean, this can make people not eat, it can make people not go outside. It can make people do things that, you know, really limits their lives, and sometimes those secondary things, like not eating, could become, you know, theoretically life threatening. But pain in and of itself is not life-threatening. So that’s the good news. But it still demands treatment most of the time.

Scott Gilbert – You’re watching Ask Us Anything About Face Pain from Penn State Health, and we welcome your questions for Dr. Jim McInerny a neurosurgeon here at Hersey Medical Center. Feel free to add them to the comment field below this Facebook post. If you know somebody who may benefit from this information, feel free to tag them in the comment field, or share this post as well on your Facebook page, and help to get the word out about this information. You know, the culprit is the irritation of that trigeminal nerve. We are talking about that before, and I heard that it also can be caused by other conditions, for example, Multiple Sclerosis, can lead to this. So there, I guess a few possible factors that can weigh in here?

Dr. Jim Mcinerney – Sure. And so one of the things that we try and do when somebody comes in with face pain is first and foremost, to determine if it is what we call typical trigeminal neuralgia. So we, that’s really what’s going on. Because the things that we do work best when it’s trigeminal neuralgia. But there are other things that can give you similar symptoms, and probably the most dramatic of those is multiple sclerosis, where you can have a very similar phenomenon, but for an entirely different reason, and giving you very similar symptoms. We do a procedure, called a micro vascular decompression, where we actually do an operation looking for that blood vessel that we think is impinging on the nerve, but if you have multiple sclerosis, there’s not going to be a blood vessel so it doesn’t make any sense to do an operation. And so we do have treatments, radiosurgery, for example, is a really good treatment for that.

Scott Gilbert – We call it gamma knife.

Dr. Jim Mcinerney – Yes, gamma knife radiosurgery, but we wouldn’t do an operation, so that’s why we have to make that distinction between. We would call face pain as a result of multiple sclerosis atypical face pain, even though it–you know, looks and sounds very much the same. But the treatment that it demands is slightly different.

Scott Gilbert – So tell me about that treatment of gamma knife, it focuses many beams of radiation in one spot. What does that do to alleviate the situation?

Dr. Jim Mcinerney – Sure, so basically all the treatments that we have, fundamentally what they do is they injure the nerve. And so with radiosurgery, and the gamma knife, what we’re doing is we are taking radiation and we’re using that to injure the nerve. But the trick with radiation is not how can you hurt something, it’s how can you not hurt everything else around it? Because obviously there are important things around that nerve that we don’t want to hurt, brain stem, and other parts of the brain for example. So the trick with the gamma knife is we actually take 192 low dose sources, beams of radiation, and point them all at the same spot. And so very accurately we are told all those beams come together in one spot, and are targeting an area that is just about 4 mm in size, and as you move away from that central spot, that dose of radiation goes down exponentially. So basically the only thing that sees enough radiation to be damaged is what we target, which in this case is the nerve, and everything else around it is totally safe. And it sees radiation, but not enough to be damaged by it.

Scott Gilbert – So you basically obliterate the nerve in that particular spot, whereas in the other type of procedure you mentioned, it involves targeting a blood vessel. You’re not obliterating the blood vessel; you’re just kind of trying to move it away from the nerve.

Dr. Jim Mcinerney – Correct, exactly. And so you know we take advantage of the fact that this is not usually a complete injury of the nerve, just the way the nerve has evolved over time, the pain carrying fibers tend to be much more sensitive, and more likely to be injured by anything we do, and as a result, very conveniently we go to injure the nerve, they get injured first, and the normal sensory fibers don’t get injured, and so usually people don’t have any numbness or anything. At, you know, any secondary effects as a result of this. They just get improvement in their pain, which is nice. When we move the blood vessel away there is probably a little bit of injury to the nerve that goes on there too, but the main thing is that we stop that ongoing process of the blood vessel, you know, hitting the nerve, constantly, over and over and over again. And so when we do that, that actually usually lasts a lot longer. That usually will last 10, 20 years or even a lifetime. But it comes with a price of a much bigger operation and more risk, more recovery, that kind of thing.

Scott Gilbert – In some cases are you able to handle this medically or is that rare?

Dr. Jim Mcinerney – Sure, well you’re asking me, I’m a surgeon, that’s how we take care.

Scott Gilbert – You’re biased, right?

Dr. Jim Mcinerney – No, but in truth, most people, as I said, one of the things we’re looking for is response to treatment, and so most people who come to us, if they haven’t already had some medical therapy, we would put them on medical therapy. Because if medicine takes care of this problem, well that is a good thing. One of the things I tell patients with trigeminal neuralgia, is you kind of have to think of this as a life-long problem. It is very highly likely that it’s going to come back again at some point, and really our first defense against that are the medications that we use. And if those medications work, then that’s usually the best thing to do. And when we get involved, it’s usually when it has responded to those medications, but it has gotten worse, and the symptoms are getting more common, more frequent, worse. And that is when we think about intervening with something, any procedure carries some risk getting some recovery with it.

Scott Gilbert – And to go back to the beginning of our conversation, toothaches and headaches often do respond to over the counter medications. The pain caused by this condition does not.

Dr. Jim Mcinerney – That’s correct, so things like, you know, Tylenol, the non-steroid anti-inflammatories like ibuprofen or naproxen, even opioid medications usually don’t help the pain of trigeminal neuralgia. The medications that usually work are actually things that are designed for seizures, things like Tegretol and Neurontin, Gabapentin, and so that’s very different types of drugs. But for whatever reason they work. We don’t completely understand that, but we know that they do, and when they do, that’s one of the things that we look to say that’s probably trigeminal neuralgia.

Scott Gilbert – We welcome your questions here on Ask Us Anything About Face pain, as we get some great information from Dr. Jim McInerny. He is a neurosurgeon here at Hersey Medical Center. Mary has a question, she says “I’ve dealt with having a headache in my temple areas and my nose literally hurts inside,” she says “this has been going on for about a year. I have a deviated septum, but it’s not that, no congestion, allergies are ruled out. She just has tests. Any ideas before I go back to the ENT?” I know you can’t diagnose her over the Internet, but here, any guidance for Mary as to how she might proceed?

Dr. Jim Mcinerney – Well and this is the kind of story we sometimes hear. And usually the next step in that kind of a situation is to see a neurologist who will be the person who usually first treats somebody with those medications. And that’s really the great way of trying to–you know, that’s the thing we can use as a tool to kind of clinch that diagnosis. If it responds to those medications, then it could be trigeminal neuralgia. And one of the things that we didn’t say about trigeminal neuralgia before, but it always affects the face, it doesn’t go into the neck or the back of the head, or even the ear usually. So you know, when you have pain that is completely, you know, staying somewhere within the realm of the face, and usually just one side, and that sounds very much like what was, you know, Mary was describing, then I think it would be a reasonable thing to try, you know, some carbamazepine, Tegretol, or Gabapentin, Neurontin, for a little while, and see whether or not that made a difference. And that is how we would typically try and make that diagnosis or rule out that as a possibility.

Scott Gilbert – Sure she can check with a neurologist for those next steps. Good stuff. Another question here from Terri. She is asking if migraines could be a symptom of trigeminal neuralgia.

Dr. Jim Mcinerney – I wouldn’t say they are a symptom, migraines are their own thing, and they’re different, but sometimes people get diagnosed with migraines when they actually have trigeminal neuralgia, so sometimes that misdiagnosis can happen. I think most of the time, migraines usually involve the whole head, they’re often accompanied with nausea and vomiting, and those are things that you don’t usually see with trigeminal–

Scott Gilbert – And also the worst pain of their life, which is similar to what you were talking about before.

Dr. Jim Mcinerney – Right, exactly, and so that’s why, the people who usually tease out these details are neurology colleagues, and again, often by a little bit of trial and error in terms of trying different medications and see what people respond to so that we can get out–okay so is this down this path or more down another path.

Scott Gilbert – Trigeminal neuralgia is more common in women than in men, and more so in people over age 50. Do we know anything, why that is the case?

Dr. Jim Mcinerney – You know, we don’t completely as I said before, it’s not an easy condition to study. But I do believe, I mean, it’s definitely more common in older people than in younger people, I mean, it certainly happens in younger people, but the majority of patients that we see are in their 60s, 70s and 80s. And you’ve got to think that in part that is because that blood vessel that causes trouble is more likely tom, you know, has spent more time against the nerve, more likely to get there over time, over the years of somebody’s life. We’re not generally born that way, so it takes some time to get there and I think that’s why we tend to see it more in older people.

Scott Gilbert – Back out a little bit, I think with any type of pain for which people are told there is no cure, because this is not–would you consider it curable or not, or maybe in some cases?

Dr. Jim Mcinerney – Well, I think you know, I always tell people to think of it as a life-long problem. Not one that they have to suffer with every day, but one that may require treatment again, so I think it’s important if you’re devising a plan for someone with trigeminal neuralgia, that you be cognizant of plan B, and plan C, and maybe plan D, because it is, unfortunately likely to come back again and we need to be ready for that eventuality and I think that way people are better prepared in general to take care of it if and when it decides to come again.

Scott Gilbert – As you’ve noted there are many ways this can be managed, even if not cured, the pain can be managed.

Dr. Jim Mcinerney – Correct, and you know, I always say the things we do are treatments, not cures, because I want to think about it that way, I want to be prepared for the next thing. We do certainly see when people have microvascular decompressions that their pain may never come back again. I think that’s a possibility, but I still want to be prepared, you know that’s my job, just be prepared, just in case. I think with gamma knife radiosurgery we often get long-term relief, 10 years or more for some people, but often we have to, you know, we will see people have the pain again and we will repeat that sometimes. If it worked once, it usually will work again.

Scott Gilbert – You’re watching Ask Us Anything About Face Pain from Penn State Health. We welcome your questions for Dr. Jim McInerny, whether you’re watching this video live, or even if you’re watching it on playback we can track down answers, and we will answer you in the comment field below this Facebook post. We have another question now from Rebecca. She is asking if there is a connection to fibromyalgia. She says she was diagnosed, and “my whole face hurts.”

Dr. Jim Mcinerney – Well again, if it’s both sides of the face, that is less likely to be trigeminal neuralgia. Fibromyalgia is a difficult thing to treat, and again, often, it’s a pain and so as with all pain it’s often a trial and error type of process to get at what is really working. I don’t–you know, there’s not really a connection between trigeminal neuralgia and fibromyalgia per se, but again, it depends on how well the diagnosis has been done. So there are people who have trigeminal neuralgia who could be diagnosed with fibromyalgia, because they were never tried on those medications, or something along those lines.

Scott Gilbert – All right, some great information today from Dr. Jim McInerny, he’s a neurosurgeon here at Penn State Health, Milton S. Hershey Medical Center. If people would like more information about the clinic and Dr. McInerny’s clinic here, we will make sure we add that to the comment field below this Facebook post, so you have that contact information. But thanks a lot for your time today.

Dr. Jim Mcinerney – Thank you.

Scott Gilbert – And we thank you for watching Ask Us Anything About Face Pain, from Penn State Health.