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1. "Dr, do something, I can't live with this shock-like severe pain over my face, repeating every 5 minutes."
This was in 2019. Mr Prasad had been suffering from this pain for >6 months. Days were like hell & nights seemed to have no end for him.
#MedTwitter #NeuroTwitter
This was in 2019. Mr Prasad had been suffering from this pain for >6 months. Days were like hell & nights seemed to have no end for him.
#MedTwitter #NeuroTwitter
2. The pain felt like electric-shocks or intense burning sensation, and occurred around eye, nose, lips, cheek and jaw on the right side. Pain lasted for 30-45 seconds and repeated every 5 minutes.
He had consulted several neurologists but no treatment seemed to work for him.
He had consulted several neurologists but no treatment seemed to work for him.
3. The clinical diagnosis was trigeminal neuralgia (TN). MRI brain was normal (didn't show any neuro-vascular conflict near right trigeminal nerve).
Several medicines such as carbamazepine, baclofen and lamotrigine only made him drowsy, without giving any relief from pain.
Several medicines such as carbamazepine, baclofen and lamotrigine only made him drowsy, without giving any relief from pain.
4. When 65-yr old Mr Prasad consulted me, he was in tears. He didn't want to live any more. "Dr I have even contemplated suicide a few times".
No wonder, trigeminal neuralgia was earlier referred to as suicide disease.
I had to do something and that needed to be done quickly.
No wonder, trigeminal neuralgia was earlier referred to as suicide disease.
I had to do something and that needed to be done quickly.
5. My neurosurgery colleague was unsure of the benefit of microvascular decompression (MVD) surgery. Moreover, in view of Mr Prasad's post coronary artery bypass graft (CABG) surgery status, high BP and blood sugars, the surgical risk was also high.
I had an idea.
I had an idea.
6. "Mr Prasad, there is a treatment, which is simple, however, it is not a "standard" of care for trigeminal neuralgia". This can be done on outpatient basis and it is fairly safe, as it is being used for treating various other neurological disorders & in cosmetic procedures.
7. I had offered botulinum toxin (Bt) injection on compassionate grounds. Mr Prasad and his family members accepted to take this treatment.
Mr Prasad noticed pain relief from day 5 onwards and by 6 weeks was almost pain-free.
He required another dose of Bt in 2020.
Mr Prasad noticed pain relief from day 5 onwards and by 6 weeks was almost pain-free.
He required another dose of Bt in 2020.
8. I didn't hear from Mr Prasad for >2 years as he remained pain-free. He returned last week with recurrence of facial pain, and wanted botulinum toxin injection (he was not interested in trying medications due to his past unpleasant experience).
9. Take home message
*Facial pain in some cases of trigeminal neuralgia can be severe and routine medications may not help alleviate pain.
*Botulinum toxin injection may be offered on compassionate grounds (after explaining pros and cons of treatment to the patient).
*Facial pain in some cases of trigeminal neuralgia can be severe and routine medications may not help alleviate pain.
*Botulinum toxin injection may be offered on compassionate grounds (after explaining pros and cons of treatment to the patient).
10. Evidence from literature:
*Mean pain score of botulinum toxin group decreased by approximately 68% (as compared to only 21.6% in placebo group) after the therapy.
*Mean frequency of TN attacks in botulinum toxin group decreased by 85%, while in placebo by only 15.9%.
*Mean pain score of botulinum toxin group decreased by approximately 68% (as compared to only 21.6% in placebo group) after the therapy.
*Mean frequency of TN attacks in botulinum toxin group decreased by 85%, while in placebo by only 15.9%.
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