Trigeminal Neuralgia

By Shirley, Barry

Hypnotherapy for Pain Reduction: Two Case Studies Abstract

Trigeminal Neuralgia (tic douloureux) has been referred to as the ‘suicide disease ‘by many of those afflicted. It is a disorder of the fifth cranial (trigeminal) nerve and can produce intense, stabbing, electric shock-like pain sensations. A less common form called Atypical Trigeminal Neuralgia may cause less intense pain sensations, ranging from a constant burning or dull ache to occasional electric shock-like stabs. This paper presents two case studies where the objective was to initially use hypnosis in a clinical situation for possible pain level reduction, and then to teach self-hypnosis for the client’s own ongoing pain management.

The incidence of trigeminal neuralgia in the general population is quite small, cited as 155 per 100,000 (Troost, 2007). It is a condition that very few hypnotherapists will be presented with and the available evidence of treating this condition by hypnosis is very limited. The generally accepted methods of treatment range from medical pain management (pain reduction drugs) to various surgical procedures. There has been some acknowledgement given to the use of complementary and alternative medicine, including hypnosis, by organisations such as the Trigeminal Neuralgia Association (Lawhern, 2006).

It is hard for us to imagine the extreme pain levels felt by people afflicted with trigeminal neuralgia. The pain has been described as so intense that it could be compared to that of biting on a needle or fracturing a tooth (Troost, 2007). Common descriptions range from lance like jabs, stabbing pains and electric shock-like sensations. The pain can last from just a few seconds to almost one minute.

The client is usually incapacitated during this time and generally attempts to immobilise the pain in the face by pressing on trigger points for pain relief. In severe cases, clients may not be able to eat, drink, or clean their teeth without experiencing some degree of pain. Due to the inconsistent pattern of pain attacks (sometimes several per day, extending to months apart), the client is understandably anxious and is unable to enjoy life without some apprehension, waiting for the next pain episode.

Trigeminal neuralgia can occur across all age groups, having even been recorded in a child as young as 16 months. It occurs predominantly in middle and old age. Around 70% of sufferers are over the age of 40, with many in this age category having hypertension or ateriosclerosis. Generally the ratio of females to males afflicted with trigeminal neuralgia is 2:1 and the right side of the face is involved more than the left in a ratio of 3:2, with the condition being bilateral in only around 2% of cases (Troost, 2007). It is not generally considered to be an inherited condition although around 5% of cases occur in same families, which may suggest a possible genetic link in these cases (Mayo Clinic, 2006).

Aetiology and Pathology

The trigeminal nerve originates deep inside the brain and its function is to carry sensations from the face to the brain. There are three branches of the nerve. The first branch controls sensations in the eye, upper eyelid, and forehead. The second branch covers the sensations from the lower eyelid, cheek, nostril, upper lid, and upper gum, while the third branch is concerned with the sensations from the jaw, lower lip and gum.

Pain generally results when there is a disturbance in the function of the trigeminal nerve (usually due to contact of the nerve by a normal artery or vein). When pressure is placed on the nerve the nerve misfires. Physical nerve damage or stress may be the initial trigger. Trauma and dental problems can also cause trigeminal neuralgia (Mayo Clinic, 2006). Other less frequent sources of trigeminal neuralgia pain are intracranial tumours (usually in the posterior fossa), multiple sclerosis, stroke (affecting the lower part of the brain), changes in myelin sheaths, and, in rare cases, drug intoxication (Troost, 2007).

There are a variety of triggers which may set off the pain. These include smiling, feeling a breeze on the face, washing, shaving, brushing teeth, applying makeup, eating and/or drinking, and stroking the face (Mayo Clinic, 2006).

Medical Treatments

Once trigeminal neuralgia is diagnosed, the first treatment option is usually through medication. Analgesics such as aspirin and paracetamol are not considered due to the rapid intensity of the attack and the usual severity of the pain level. The primary drug used to treat trigeminal neuralgia is carbamazepine (available as Tegretol) which is administered slowly at first and gradually increased to a level that allows the client to be pain free. The initial relief achieved by this drug is very effective and many physicians use it to confirm the diagnosis of trigeminal neuralgia. A newer medication is oxcarbazepine (available as Trileptal) which is now considered preferable due to a more favourable side effect profile (Lawhern, 2006). There are other medications available, increasing in numbers with further research.

In cases where medications are not effective in pain reduction pain blocking procedures may be used.

* Glycerol Injection

A needle is inserted through the face into the base of the skull and guided into the trigeminal cistern (a small sac of spinal fluid around the trigeminal nerve ganglion). Glycerol is injected to damage the trigeminal nerve and render it insensitive.

* Balloon Compression

In this procedure a hollow needle is inserted near the nerve and a balloon inflated, exerting enough pressure to damage the nerve.

* Microvascular decompression

Blood vessels are surgically removed or relocated and separated from the nerve by a small pad. This is one of the more successful surgical procedures for this condition.

Other surgical procedures involve severing the nerve (partial sensory rhizotomy) and radiation (gamma-knife radiosurgery) to damage the nerve. Each procedure has risks and these can range through muscle damage, ongoing pain and numbness, stroke, and even death (Mayo Clinic, 2006).

Complementary and Alternate Medicine

Alternative medical therapy has been acknowledged as increasingly popular with an estimate of one person in three at some time using these therapies for pain problems, anxiety, and mind-body interactions (Sadock & Sadock, 2003). The American TNA (Trigeminal Neuralgia Association) has been accumulating anecdotal data on non- traditional remedies found helpful by patients to treat their pain relief. They are in the process of assembling a task force to establish guidelines for patients to follow when seeking alternate help and to share the data collected. Hypnosis has been included in their list of therapies where some success in pain reduction has been achieved (Lawhern, 2006). Due to the sudden and extreme nature of the pain from trigeminal neuralgia, hypnotherapy requires reinforcement to maintain the pain reduction, and teaching self- hypnosis can provide some ongoing support for the patient (Marriott, 1981).

In my own particular practice, there are two case studies that present different aspects in the use of hypnosis when applied to trigeminal neuralgia.

Case Study One – September 2006

Female, aged 60 years, single, retired ex-school teacher, experiencing acute trigeminal neuralgia pain. The initial onset of the condition was subtle and probably resulted from facial trauma injuries received in a car accident some 10 years earlier. 12 months prior to her first consultation with me she had a microvascular decompression medical procedure relocating blood vessels away from the trigeminal nerve in the third area (jaw), right hand side of the face and the insertion of pads to separate the nerve from surrounding muscle. Subsequent to the operation, the pain level and the incidence of attacks increased. On some days she could experience several attacks and then not have any for some time, but all attacks were accompanied by hysterical screaming over which she had no control. Most of the attacks lasted from approximately 20 seconds up to one minute, but her worst attack went for 30 minutes. She described each attack as an electric shock producing excruciating pain. The pain attacks were increasing in both quantity and intensity. In addition to the anxiety of anticipating an attack, she was under severe stress resulting from her brother’s terminal cancer condition.

In the first session an extensive history was taken It was noted that she was medicating with Tegretol which was having less effect on the pain intensity. Her face was noticeably contorted on the right hand side, and she reported experiencing insomnia and anxiety which were impacting on her enjoyment of life. Hypnosis 30 years previously to overcome exam stress had worked well. We discussed a possible three-part strategy to help reduce her pain levels

* To use glove anaesthesia to help numb the painful area along her jaw line

* To use suggestions that her level of pain intensity during an attack would be reduced to a more acceptable level

* To teach her self-hypnosis to achieve better relaxation levels to enable her to sleep.

She responded well to a visualisation/induction test (Alien, 2005) to gauge her level of suggestibility. I then used the Elman- Banyan Rapid Hypnotic Induction (Banyan & Kein, 2001) but with a modification involving more widespread muscle relaxing than just the eyes. Once somnambulism was achieved, I further deepened the level of trance following the Elman-Banyan method of counting from one to five. During the induction I suggested that the back of her right hand was extremely numb, and that she could transfer this numb feeling to the painful areas of her face. She moved her hand to her face and began stroking her right jaw from mouth to ear. I also suggested that the level of pain she would feel from now on would be more of a tingling sensation than a sharp pain, and that the number of pain attacks would reduce. She was to use the back of her right hand to induce numbness to her face whenever she had another attack, to limit the pain level. It was further suggested that she would be able to induce herself to this deep level of relaxation using self- hypnosis when at home. I then proceeded to awaken her with a count from one to five, with five allowing her to return to the room, completely awake, pain-free and looking forward to the rest of her day. It was surprising that she admonished me for awakening her too soon as she found it difficult to return in a relaxed state. I immediately reintroduced her to a deep level of hypnosis and slowly used a count often. This time she responded well to wakening. (Note: a count of ten was used for each of the subsequent sessions with good results.) At the conclusion of the first session, she was experiencing a pleasant numbness in her face and she was pain-free. The contorted right side of her face appeared far more relaxed.

The second session was conducted 15 days later due to a full schedule of medical tests including an MRI scan. She had had a stressful week with several pain attacks so rapid and unexpected that there was no time to even think about the glove anaesthesia. We concluded that using this method would not be successful due to the rapidity of the attacks and that further work would be directed toward lessening the intensity of the pain. She had increased her Tegretol medication and was experiencing blurred vision and noticing weight gain. It was difficult to assess whether any level in pain reduction was attributable to the hypnosis or to the increase of Tegretol. This session was used to suggest that her trigeminal nerve would stop firing abnormal signals to cause a pain attack (Waxman, 1993). She was able to visualise the trigeminal nerve functioning normally and her pain levels reducing. Further teaching of self- hypnosis continued as she reported having had a better sleep pattern and being able to relax during the day. There was no pain attack during these self-hypnosis periods and her level of anxiety had reduced markedly, with more relaxed facial muscles on her right hand side. It is interesting to note that she was using the visualization of a rose garden for relaxation (which we had used in the first session) which seemed to deepen her level of self-hypnosis.

The third and final session took place 15 days later. She had experienced only two minor attacks of pain. The intensity of pain had diminished and she was far more relaxed. It appeared that the suggestions of pain level reduction and the continuing use of self- hypnosis were showing some promise. Further work on using this same strategy was conducted. In a telephone conversation approximately two months later, she was quite happy with the results achieved by the hypnosis but had decided to follow her medical practitioners advice and have another medical procedure, this time a partial sensory rhizotomy to sever the nerve. There was no further contact from this time.

Case Study Two – December 2006

Male aged 61 years, retired engineer and toolmaker. In 1980, he was involved in a serious car accident and suffered severe injuries to his face and cervical spine, becoming a paraplegic. He was unable to stop his head from falling forward which led to further surgery to the neck and spine, requiring the insertion of metal plates. After this operation, he experienced acute trigeminal neuralgia pain to the left side of his head in the jaw region. This remarkable man then taught himself to walk again with the aid of walking sticks and to drive a car with his own specially made mechanical device. Over the years he had microvascular decompression surgery with pad insertion around the trigeminal nerve without much reduction in pain level. A second surgical procedure involved severing the trigeminal nerve in a partial sensory rhizotomy surgical procedure, following which he had a stroke. He had to teach himself to walk again.

The pain level resulting from the second operation and the stroke was described as a constant ache, as if several teeth had been extracted. His pattern of sleep was extremely poor. The stroke caused optical nerve damage requiring special glasses to correct blurred vision. Extensive dental work had been ongoing since the car accident. During the first session and the history taking, he kept referring back to his many dental sessions and the effect of the Novocaine giving him some relief from the pain until it wore off. This provided a good foundation for a hypnosis strategy and once it was established that he could achieve a somnambulism level of trance using the Elman-Banyan Rapid Hypnotic Induction (Banyan & Kein, 2001) he was asked to visualise the word “calm” and to feel the effects of Novocaine spreading through his jaw. Instructions for self-hypnosis were also given while he was under trance, using the word “calm” as a trigger to induce relaxation and a pain deadening effect.

The second session was conducted 12 days later, due to the Christmas break He reported some initial pain relief but a serious head cold had confined him to bed and his pain had returned to the previous intensity level. His left facial muscles (zygomaticus, masseter, and orbicularis oculi) were noticeably tight. A somnambulism level of trance was achieved and he was asked to relax his facial muscles and to think of the word calm’ and the Novocaine effect of pain reduction. He was awakened and asked how he felt. There was no pain and his facial muscles appeared quite relaxed. He was asked to return to his previous level of trance and the Elman- Banyan method of counting from one to five for deepening was applied (Banyan & Kein, 2001). Further suggestions were made to increase the association of the word cairn with the pain lowering effect of Novocaine and self-hypnosis instructions reinforced.

The third and final session took place five days later with some surprising results. His pain level was now quite manageable even though the week had been stressful following a very expensive car repair problem. His sleep pattern had improved markedly. He lived in a two storey house and it usually took him 15 minutes to climb the stairs to his bedroom. He had started using self-hypnosis (initially following my self-hypnosis CD specially recorded for him) after this exhaustive stair climb each night just before sleeping. He was so relaxed that he allowed himself to drift oft” to sleep at the end of the self-hypnosis. Whenever he started to experience pain increasing, he consciously thought of the word “calm” and the pain level reduced to what he described as a tolerable level (Meares, 1979). The session was spent reinforcing the same strategy and allowing him to achieve his own trance state with self-hypnosis. A follow-up telephone call approximately three months later confirmed that he was still happy with the results, especially the self- hypnosis and its application to help him sleep.

Conclusion

My previous experience of using hypnosis for pain management problems had been mainly confined to helping clients with headache, neuralgia, and relief from chronic pain. When I was asked via a referral to help my female client with trigeminal neuralgia, I set out to research the condition and the application of hypnosis to help relieve the pain. There was very little literature available and a request for information from colleagues on an online forum produced only a limited amount of information. Even information on other alternate forms of therapy in the treatment for trigeminal neuralgia such as chiropractic, acupuncture, and others was very limited. It appeared that self-hypnosis was probably the best application of hypnosis for these unfortunate people suffering from this dreadful affliction. It is encouraging to note that the Trigeminal Neuralgia Association and its various branches are collecting data and appear to have an open mind toward the use of what they term ‘CAM’ (complementary and alternative medicine).

In my own limited experience with trigeminal neuralgia clients I have made some observations that could be helpful to other practitioners. The debilitating effect of the pain attacks reduces sufferers to an almost helpless state where they are unable to think of anything other than the pain itself. Due to the rapid and completely unexpected onset of the severe pain attacks, the use of conventional analgesic hypnotic methods, such as glove anaesthesia, would be unsuitable.

However, teaching self-hypnosis is of benefit to these clients. They can practice it whenever they wish and it does appear to have beneficiai results in reducing anxiety and helping them achieve a better sleep pattern. Reduced anxiety levels can help clients relax during the periods in between the attacks, and to help reframe their pain levels to a more acceptable state. This can only aid in helping them to strengthen themselves between pain attacks, and to allow some comfort beyond just waiting to face the uncertainty of the next attack.

References

Allen, R.P. (2005). Scripts, strategies in hypnotherapy: The complete works. Bancyfelin, Wales: Crown House.

Banyan, C.D. & Kein, G.F. (2001). Hypnosis and hypnotherapy: Basic to advanced techniques and procedures for the professional. Minnesota: Abbot Publishing House.

Lawhern, R.A. (2002). Choosing between treatments for trigeminal neuralgia. http://www.tna-support.org/newlook/ Articles/Choose.htm Marriott, J.A. (1981). Hypnosis and the relief of pain. The Australian Journal of Clinical Hypnotherapy & Hypnosis, 2(2).

Mayo Clinic http://www.mayoclinic.com/ health/trigeminal- neuralgia/DS00446

Meares, A. (1979). Relief without drugs. Melbourne: Fontana Collins.

Sadock. B.J. & Sadock, V.A. (2003). Synopsis of psychiatry. Philadelphia: Lippincott, Williams & Wilkins.

Troost, T. (2007). Web Master for http://www. imigraine.net/ other/mtic.html

Waxman, D. (1993). Hartland’s medical and dental hypnosis. London: Balliere Tindall.

Barry Shirley

Hypnotherapist, West Ryde NSW Australia

Barry Shirley is a qualified and practicing Clinical Hypnotherapist and a registered Counsellor with a private practice in West Ryde, Sydney. He is a qualified and registered remedial masseur with the ATMS, specialising in pain management.

Copyright Australian Society of Clinical Hypnotherapists Autumn 2008

(c) 2008 Australian Journal of Clinical Hypnotherapy and Hypnosis. Provided by ProQuest LLC. All rights Reserved.

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