Cranial neuralgias are distinct, treatable syndromes which comprise one of the possible causes of facial pain. The cranial neuralgias include the following:

• Trigeminal Neuralgia (which is the most common)
• Neuralgia secondary to nervus intermedius pathology
• Glossopharyngeal Neuralgia

One of the major causes is thought to be vascular compression at the root entry zone of the trigeminal nerve . Tumor and multiple sclerosis are also important causes. Most patients initially respond to medical management with carbamazepine (Tegretol), phenytoin (Dilantin), and lioresal (Baclofen). However, unacceptable long-term side effects and suboptimal pain relief despite dose augmentation over time are indications for surgical consultation.

If medication does not help, or the side effects are intolerable, then further treatment may be required. Two common procedures include glycerol rhizotomy and gamma knife radiosurgery. Rhizotomy involves an injection under x-ray guidance into/near the trigeminal nerve at the base of the skull. Gamma Knife is used to apply a focal, but high dose of radiation to the trigeminal nerve. Both are ambulatory procedures.

Trigeminal Neuralgia and Microvascular Decompression

Trigeminal neuralgia can also be treated successfully through microvascular decompression, which is a relatively safe and novel technique popularized by Dr. Peter Jannetta. The concept of surgery was developed from information that an abnormal vessel (or a vessel in an abnormal location) in the vicinity of the 5th cranial nerve, due to its constant and continuous pulsations, produces pressure on the nerve, resulting in excruciating pain. In the technique of microvascular decompression, the vessel is mobilized and separated from the nerve with a teflon felt. In this way, the vessel is prevented from transmitting its pulsations to the nerve. The cure rate with this procedure is higher than with other procedures such as glycerol injection and radiofrequency lesioning. The side effects, such as anesthesia dolorosa, are virtually nil. Pain relief is immediate and permanent.