Neuralgia

Not to be confused withNeuroglia.

This article is about pain in the distribution of a nerve or nerves. For pain caused by a lesion or disease of the somatosensory nervous system, seeNeuropathic pain.

Neuralgia
Specialty	Neurology

Neuralgia(Greekneuron,"nerve" +algos,"pain" ) is pain in the distribution of a nerve or nerves,as inintercostalneuralgia,trigeminal neuralgia,andglossopharyngealneuralgia.

Classification

Under the general heading of neuralgia aretrigeminal neuralgia(TN), atypical trigeminal neuralgia (ATN),occipital neuralgia,glossopharyngeal neuralgia andpostherpetic neuralgia(caused byshinglesorherpes). The termneuralgiais also used to refer to pain associated withsciaticaandbrachial plexopathy.

Atypical (trigeminal)

Main article:Atypical trigeminal neuralgia

Atypical trigeminal neuralgia (ATN) is a rare form of neuralgia and may also be the most misdiagnosed form. The symptoms can be mistaken formigraines,dental problems such astemporomandibular joint disorder,musculoskeletal issues, andhypochondriasis.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. ATN pain can be described as heavy, aching, and burning. Affected individuals have a constant migraine-like headache and experience pain in all three trigeminal nerve branches. This includes aching teeth, ear aches, feeling of fullness in sinuses, cheek pain, pain in forehead and temples, jaw pain, pain around eyes, and occasional electric shock-like stabs. Unlike typical neuralgia, this form can also cause pain in the back of the scalp and neck. Pain tends to worsen with talking, facial expressions, chewing, and certain sensations such as a cool breeze. Vascular compression of thetrigeminal nerve,infections of the teeth or sinuses, physical trauma, or past viral infections are possible causes of ATN.

In the case of trigeminal neuralgia, the affected nerves are responsible for sensingtouch,temperature sensationandpressure sensationin thefacialarea from thejawto theforehead.The disorder generally causes short episodes of excruciatingpain,usually for less than two minutes and usually 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 presents as severe constant aching along the nerve. The pain associated with TN is recognized as one of the most excruciating pains that can be experienced.

Simple stimuli—such as eating, talking, making facial expressions, washing the face, or any light touch or sensation—can trigger an attack (even the sensation of a cool breeze). Attacks may be lone occurrences, clusters of attacks, or constant episodes. Some patients experiencemuscle spasm,which led to the original term for TN of "tic douloureux"("tic",meaning"spasm",and"douloureux",meaning" painful ", inFrench).

Glossopharyngeal

Glossopharyngeal neuralgia consists of recurring attacks of severe pain in the back of the throat, the area near the tonsils, the back of the tongue, and part of the ear. The pain is due to malfunction of theglossopharyngeal nerve(CN IX), which moves the muscles of the throat and carries information from the throat, tonsils, and tongue to the brain.

Glossopharyngeal neuralgia, a rare disorder, usually begins after age 40 and occurs more often in men. Often, its cause is unknown. However, glossopharyngeal neuralgia sometimes results from an abnormally positioned artery that compresses the glossopharyngeal nerve near where it exits the brain stem. Rarely, the cause is a tumor in the brain or neck.

Occipital

Occipital neuralgia,also known as C2 neuralgia, or Arnold's neuralgia, is a medical condition characterized by chronic pain in the upper neck, back of the head and behind the eyes.

Mechanisms

By understanding the neuroplastic changes following nerve damage, researchers may be able to gain a better understanding of the mechanism of hyperexcitability in the nervous system that is believed to cause neuropathic pain.

Peripheral nerve injury

A neuron's response to trauma can often be determined by the severity of the injury, classified bySeddon's classification.In Seddon's Classification, nerve injury is described as eitherneurapraxia,axonotmesis,orneurotmesis.Following trauma to the nerve, a short onset of afferent impulses, termed "injury discharge", occurs. This occurrence lasts only minutes, but has been linked to the onset of neuropathic pain.

When anaxonis severed, the segment of the axon distal to the cut degenerates and is absorbed bySchwann cells.The proximal segment fuses, retracts, and swells, forming a "retraction bulb". Thesynaptic terminalfunction is lost, asaxoplasmictransport ceases and noneurotransmittersare created. The nucleus of the damaged axon undergoeschromatolysisin preparation for axon regeneration. Schwann cells in the distal stump of the nerve andbasal laminacomponents secreted by Schwann cells guide and help stimulate regeneration. The regenerating axon must connect to the appropriate receptors to make an effective regeneration. If proper connections to the appropriate receptors are not established, aberrantreinnervationmay occur. If the regenerating axon is halted by damaged tissue, neurofibrils may create a mass known as aneuroma.

If an injured neuron degenerates or does not regenerate properly, then the neuron loses its function or may not function properly. Neuron trauma is not an isolated event and may cause degenerative changes in surrounding neurons. When one or more neurons lose their function or begin to malfunction, abnormal signals sent to the brain may be translated as painful signals.

Diagnosis

When assessing neuralgia to find the underlying mechanism, a history of the pain, description of pain,physical examination,and experimental examination are required. Pain is subjective to the patient, but pain assessment questionnaires, such as theMcGill Pain Questionnairecan be useful for evaluation.Physical examinations usually involve testing responses to stimuli such as touch, temperature, and vibration. Neuralgia can be further classified by the type of stimuli that elicits a response: mechanical, thermal, or chemical. Response to the course of treatment is the final tool used to determine the mechanism of the pain.Additional tools may be used, predominantly in research settings including Laser Evoked Potentials and Quantitative Sensory testing.

Laser evoked potentials

Laser evoked potentials (LEPs) are measurements of cortical responses using lasers to selectively stimulate thermonociceptors in the skin. Lasers can emit a radiant-heat pulse stimulus to selectively activate A-delta and C free nerve endings. LEP abnormalities may be indicative of neuropathic pain, while a normal LEP is often more ambiguous. LEPs can assess damage to both central and peripheral nervous systems.

Quantitative sensory testing

Main article:Quantitative sensory testing

Another method for testing the proper function of a nerve is Quantitative sensory testing (QST). QST relies on analysis of a patient's response to external stimuli of controlled intensity. A stimulus is applied to the skin of the nerve area being tested in ascending and descending orders of magnitude. Clinicians can quantify the mechanical sensitivity of the tactile stimulus usingvon Frey hairsor Semmes-Weinstein monofilaments (SWMFs). Also, weighted needles can be used to measure pin-prick sensation, and an electronic vibrameter is used to measure vibration sensitivity. Thermal stimuli are quantified by using a probe that operates on the Peltier principle.

Treatment

Treatment options include medicines and surgery.

Neuralgia is more difficult to treat than other types of pain because it does not respond well to normal pain medications. Special medications have become more specific to neuralgia and typically fall under the category of membrane stabilizing drugs orantidepressantssuch asduloxetine(Cymbalta). The antiepileptic medicationpregabalin(Lyrica) was developed specifically for neuralgia and other neuropathic pain as a successor togabapentin(Neurontin).

High doses of anticonvulsant medicines—used to block nerve firing— and tricyclic antidepressants are generally effective in treating neuralgia. If medication fails to relieve pain or produces intolerable side effects, surgical treatment may be recommended.

Neural augmentative surgeries are used to stimulate the affected nerve. By stimulating the nerve the brain can be "fooled" into thinking it is receiving normal input. Electrodes are carefully placed in the dorsal root and subcutaneous nerve stimulation is used to stimulate the targeted nerve pathway. A technician can create different electrical distributions in the nerve to optimize the efficiency, and a patient controls the stimulation by passing a magnet over the unit.

Some degree of facial numbness is expected after most of these surgical procedures, and neuralgia might return despite the procedure's initial success. Depending on the procedure, other surgical risks include hearing loss, balance problems, infection, and stroke. These surgeries includerhizotomy(where select nerve fibers are destroyed to block pain) andmicrovascular decompression(where the surgeon moves the vessels that are compressing the nerve away from it and places a soft cushion between the nerve and the vessels).

History

The earliest cited instance of the termis the French,névralgie,which, according to Rowland,was coined byFrançois Chaussierin his 1801Table Synoptique de la Névralgie,for "...an affection of one or more nerves causing pain which is usually of an intermittent but frequently intense character".The features and assumedetiologyfound in the medical literature have varied significantly over time.

Various locations were proposed for the primarylesionduring the nineteenth century, including nerveroots,ganglia,trunksand branches, as well as the brain and spinal cord. In 1828, JC Warrenand TJ Grahamplaced the cause in the trunk or branch of the nerve innervating the perceived site of the pain, though Graham also attributed neuralgia to "morbid sensibility of the nervous system" due to "great disorder of the general health". Teale in 1830and many after him argued that it may be located in the spinal cord or nerve root. Later in the century some proposed it may be an affliction of organs such as the uterus or liver, while others classed certain headaches as neuralgias, and proposed that emotional distress may promote the condition.

Society and culture

• InR. C. Sherriff's playJourney's End,the character Hibbert lies about having neuralgia to his commanding officer, and demands to be sent home.
• InMarcel Proust'sSwann's Way,the father of the narrator has neuralgia.
• In the 1976 filmAces High,a Britishacein theRoyal Flying Corps(played bySimon Ward) feigns neuralgia to escape the terrors of aerial combat.
• The narrator ofVladimir Nabokov's novelLook at the Harlequins!claims to have neuralgia of the jaw.

See also

• Cranial nerves
• Nerve
• Neuritis
• Neuropathic pain
• Neuropathy

Further reading

• Shankland, Dr. Wesley E.Face the Pain: The Challenge of Facial Pain,(Omega Publishing, 2001). Dr. Shankland is a former associate editor ofThe Journal of Craniomandibular Practice.