Introduction

Trigeminal neuralgia (TN) is a relatively common neurological condition of the trigeminal nerve afffecting roughly 12.6-28.9/100,000 people per year.¹ The etiology of TN is still unclear and thus the classification is based on the etiology, TN is classified into idiopathic, classic, and TN because of a secondary neurological condition. When the cause is unknown idiopathic, this only makes up about 10% of TN cases.² Classic presentation is due solely to neurovascular contact and no other neurological conditions.³ TN has a prevalence for women at a rate of 3:1 and a typical age range of 37 to 67 years old.⁴

TN has a sudden onset of severe unilateral face pain, often described as sharp or electric in nature. It can last anywhere from a few seconds to over an hour.⁵ Paroxysms are essential to the diagnosis of TN, with pain never extending behind the ear or below the mandible.⁶ Other considerations must be made to include cervical nerves in these instances.

Imaging is not needed for the diagnosis; however, 15% of people with TN have another condition associated with it, such as tumor.⁷ In addition, there may be contact with the trigeminal nerve in 89% of symptomatic individuals and 35% of asymptomatic individuals as seen on MRI.⁸ Thus, MRI is highly sensitive, but not very specific for diagnosing TN. Electrodiagnostic testing and reflex testing have also shown to be effective at detecting TN, with a pooled sensitivity of 94% and a pooled specificity of 87%.^6,9

Case Report

A 45-year-old female sought care for numbness in the tip of her nose she had noticed while using a tissue to blow her nose. She also had right-sided jaw pain for month prior to seeking treatment. Based on presentation and exam findings, we diagnosed her with trigeminal neuralgia and began a course of conservative chiropractic care. She experienced pain that extended from her right temporomandibular joint and followed the maxillary distribution of the trigeminal nerve, palpable muscle spasm of her right masseter and buccinator muscles and numbness in the tip of her nose. The chiropractic manipulative therapy (CMT) consisted of Activator technique^TM to the right temporomandibular joint (TMJ) and Thompson drop technique to the cervical spine. Treatment was conducted using an Activator IV on setting 1. Line of drive on the TMJ was superior to inferior and lateral to medial.

The patient was treated for 2 months with this conservative treatment. She experienced resolution of symptoms after the 2 months of compliant care. Since then, she required treatment only once due to a slight numbness in the tip of her nose along with jaw pain. Again, her symptoms resolved with a single Activator treatment to the TMJ.

Discussion

Trigeminal neuralgia (TN) is not only the most common craniofacial neuropathic pain; it is one of the most painful neuropathic pain conditions.¹⁰ The Trigeminal nerve is divided into 3 separate branches: Ophthalmic (V1), Maxillary (V2), and Mandibular (V3). The Ophthalmic branch is the smallest of the 3 branches and is purely sensory, innervating the skin and mucous of the head and the front of the nose.¹¹ The pain distribution is dependent on the involved branch of the Trigeminal nerve. In about 60% of cases, either the Mandibular or Maxillary branch is involved; in 35% of cases both the Mandibular and Maxillary branches are involved, and in only 4% of cases, the Ophthalmic branch is involved.^10,12

There are a number of treatment options; however, none are universally agreed upon and much controversy exists regarding treatment. Pharmacological treatment seems to be the most widely accepted and used form of treatment; however, few randomized control trials exist and many of the medications are associated with significant side effects.⁶ Surgical intervention is used for those cases that fail to respond to pharmacological intervention. Microvascular decompression and radiosurgical treatment are the 2 most common surgical interventions, with a success rate of 86.9% and 71.1% respectively.¹³ There is scant literature about chiropractic treatment of TN; however, given the lack of consensus of definitive treatment options, for patients that do not wish to utilize pharmacological or surgical interventions chiropractic care may be considered.⁷

Conclusion

Further research is needed to make any substantial claim regarding chiropractic treatment for TN, especially since up to 63% percent of cases go into remission that may last for years.⁴ Developing theory suggests that neuron excitability can be influenced by chiropractic treatment.¹ The effects of these findings are not yet understood, and more research is still needed to understand the influence that chiropractic has on the nervous system.